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any prescription or non-prescription medication?","required":true,"answerOption":[{"valueCoding":{"code":"1","display":"Yes"}},{"valueCoding":{"code":"0","display":"No"}}]},{"type":"string","linkId":"282204433287","code":[{"system":"https://www.faa.gov/pilots/medical_certification","code":"17a1","display":"Enter in medication name"}],"text":"What is the name of the medication that the patient is currently taking?","enableWhen":[{"question":"3764621580219","operator":"=","answerCoding":{"code":"1","display":"Yes"}}],"repeats":true},null],"_id":"5vauzK92h5nrcxQ7N"} {"id":"fasi","responseType":"QuestionnaireResponse","status":"draft","authored":"2024-04-27T18:21:32.181Z","item":[{"linkId":"Section-37/GG0175A","prefix":"GG0175A","text":"Does the patient or resident use a manual wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0175F","prefix":"GG0175F","text":"Does the patient or resident use a motorized wheelchair and/or scooter?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0125B1","prefix":"GG0125B1","text":"Does the patient use an assistive device such as a standard folding walker?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170HH","prefix":"GG0170HH","text":"Does the patient or resident have the ability to walk?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No, and walking goal is not indicated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA31067-4","display":"No, and walking goal is not indicated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"No, and walking is indicated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA31068-2","display":"No, and walking goal is indicated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-6/F0900A1","prefix":"F0900A1","text":"Please identify the usual living arrangement of the patient or resident during the past three days.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident} lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30925-4","display":"Person lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident} lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30926-2","display":"Person lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident} lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30927-0","display":"Person lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident} does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30928-8","display":"Person does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident} was in a medical facility."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30929-6","display":"Person was in a medical facility."}}]},{"linkId":"Section-37/GG0125B","prefix":"GG0125B","text":"Does the patient use an assistive device such as a walker?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Z","prefix":"GG0125Z","text":"Does the patient use an assistive device other than the ones previously mentioned?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125A","prefix":"GG0125A","text":"The patient uses an assistive device, specifically a cane or a crutch.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125AA","prefix":"GG0125AA","text":"In the past month, has the patient used, or expressed or demonstrated a need for an assistive device?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}}]},{"linkId":"Section-6/F0910A","prefix":"F0910A","text":"Does the patient or resident have assistance in their home? The options are \"Yes\" or \"No\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170X7","prefix":"GG0170X7","text":"The patient's usual performance indicates their ability to walk across a street before the light turns red.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170E7","prefix":"GG0170E7","text":"The form inquires about the patient's usual performance in terms of their ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170J7","prefix":"GG0170J7","text":"Does the patient have the ability, once standing, to walk at least 50 feet and make two turns as part of their usual performance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920E1","prefix":"F0920E1","text":"Has the patient paid for medical procedures or treatments, such as changing wound dressings or home exercise programs?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920B2","prefix":"F0920B2","text":"Does the patient require mobility assistance, such as help with bed mobility, transfers, ambulating, or wheeling, and is this assistance unpaid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170K7","prefix":"GG0170K7","text":"Once the patient is standing, they should have the ability to walk at least 150 feet in a corridor or similar space. The usual performance is evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170F8","prefix":"GG0170F8","text":"The form inquires about the patient's ability to transfer to and from a toilet or commode, asking whether their performance is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170D7","prefix":"GG0170D7","text":"Does the patient typically have the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920H1","prefix":"F0920H1","text":"Does the individual advocate or facilitate the patient's participation in appropriate medical care, for example, providing transportation to or from appointments? The options for this are either paid or unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170M7","prefix":"GG0170M7","text":"The form asks about the patient's usual performance in the ability to go up and down a curb and/or up and down one step.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170W8","prefix":"GG0170W8","text":"The patient's ability to walk for 15 minutes without stopping or resting, like through a department store or supermarket, is the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170B7","prefix":"GG0170B7","text":"The form asks about the patient's usual ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130F7","prefix":"GG0130F7","text":"The form asks about the patient's usual performance in terms of their ability to dress and undress their upper body, including handling fasteners if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170X8","prefix":"GG0170X8","text":"The form asks the patient about their ability to walk across a street before the light turns red, with the most dependent performance as an answer choice.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170N7","prefix":"GG0170N7","text":"The form is asking about the patient's usual performance in regards to their ability to go up and down four steps, with or without using a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175B8","prefix":"GG0175B8","text":"Once seated in their manual wheelchair, the patient has the ability to wheel at least 50 feet and make two turns, indicating a most dependent performance level.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920F1","prefix":"F0920F1","text":"Does the patient manage their equipment, for example, oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies, and is it paid for?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920D2","prefix":"F0920D2","text":"Does the patient administer their medication themselves (for example, oral, inhaled, or injectable medications) without any paid assistance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0910B2","prefix":"F0910B2","text":"Please indicate the level of both paid and unpaid assistance in the patient's or resident's home during the past month. The level of assistance was unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No assistance received"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12345-7","display":"No assistance received"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Occasional/short-term assistance"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30934-6","display":"Occasional/short term assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Regular night-time"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30935-3","display":"Regular night-time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Regular daytime"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12164-2","display":"Regular daytime"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Around the clock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12163-4","display":"Around the clock"}}]},{"linkId":"Section-37/GG0130H7","prefix":"GG0130H7","text":"The form asks the patient to evaluate their usual performance in putting on and taking off socks, shoes, or other footwear appropriate for safe mobility. This includes handling fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170O8","prefix":"GG0170O8","text":"The form asks the patient to assess their ability to go up and down 12 steps with or without a rail, with the most dependent performance being the possible response.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130G7","prefix":"GG0130G7","text":"The form asks about the patient's usual performance in their ability to dress and undress below the waist, including fasteners, excluding footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170M8","prefix":"GG0170M8","text":"The form asks about the patient's ability to go up and down a curb and/or up and down one step. The patient's performance is most dependent in this activity.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175G8","prefix":"GG0175G8","text":"Once seated in their motorized wheelchair or scooter, the patient has the ability to wheel at least 50 feet and make two turns. However, their performance indicates that they are most dependent on this form of mobility.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920H2","prefix":"F0920H2","text":"Does the person facilitate or advocate for the patient's participation in appropriate medical care, for instance, by transporting them to or from appointments, without any charge?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0910B1","prefix":"F0910B1","text":"Please indicate the level of both paid and unpaid assistance in the patient's or resident's home during the past month. The choices are \"Paid\", \"Unpaid\", or \"Both Paid and Unpaid\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No assistance received"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12345-7","display":"No assistance received"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Occasional/short-term assistance"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30934-6","display":"Occasional/short term assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Regular night-time"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30935-3","display":"Regular night-time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Regular daytime"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12164-2","display":"Regular daytime"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Around the clock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12163-4","display":"Around the clock"}}]},{"linkId":"Section-37/GG0175B7","prefix":"GG0175B7","text":"The form asks about the patient's ability to wheel at least 50 feet and make two turns once seated in a manual wheelchair, assessing their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170I7","prefix":"GG0170I7","text":"The form asks about the patient's usual performance in terms of their ability to walk at least 10 feet once standing, whether it be in a room, corridor, or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170L7","prefix":"GG0170L7","text":"The form asks about the patient's usual performance in the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, both indoors and outdoors.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170U8","prefix":"GG0170U8","text":"The form asks about the patient's ability to walk from one room to another, maneuver around furniture, and navigate other obstacles indoors. The label classifies the patient's performance as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175C8","prefix":"GG0175C8","text":"Once the patient is seated in the wheelchair, they should have the ability to wheel at least 150 feet in a corridor or similar space. The choices for this ability are with a manual wheelchair or indicating the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185F8","prefix":"GG0185F8","text":"The form asks about the patient's ability to answer a telephone call in their customary manner and maintain it for 1 minute or longer. This does not include getting to the phone. The label for the most dependent performance is used.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185K7","prefix":"GG0185K7","text":"The patient's usual performance in simple financial management includes the ability to complete financial transactions such as counting coins, verifying change for a single item transaction, writing a check, online/mobile bill pay, banking, or shopping.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175E7","prefix":"GG0175E7","text":"The form is asking about the patient's ability to wheel across a street using a manual wheelchair before the light turns red. The patient usually performs this task with their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130F8","prefix":"GG0130F8","text":"The form asks about the patient's ability to dress and undress above the waist, including dealing with fasteners if applicable, and the patient's most dependent performance is being evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175H7","prefix":"GG0175H7","text":"Once the patient is seated in the wheelchair or scooter, does he or she have the ability to wheel at least 150 feet in a corridor or similar space? The options are: Motorized Wheelchair/Scooter or Usual Performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170C7","prefix":"GG0170C7","text":"The form asks about the patient's usual performance in the ability to move from lying on their back to sitting on the side of the bed with their feet flat on the floor, and without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130G8","prefix":"GG0130G8","text":"The form asks about the patient's ability to dress and undress below the waist, including handling fasteners, but not including footwear. It indicates that the patient's performance in this area is mostly dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130D8","prefix":"GG0130D8","text":"The form asks about the patient's ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed. The performance level indicated is \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170K8","prefix":"GG0170K8","text":"The form asks if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The performance level is gauged as 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185E8","prefix":"GG0185E8","text":"The patient's performance level in light shopping is at its most dependent. Once at the store, they can locate and select up to five needed goods, take them to the checkout, and complete the purchasing transaction.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170W7","prefix":"GG0170W7","text":"Does the patient have the ability to walk for 15 minutes without stopping or resting, such as through a department store or supermarket, as part of their usual performance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170V7","prefix":"GG0170V7","text":"The form asks whether the patient has the ability to carry something in both hands, such as several dishes, a light laundry basket, or a tray with food, while walking indoors. The category for this question is 'Usual Performance.'","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170D8","prefix":"GG0170D8","text":"The form asks about the patient's ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. The patient's performance is most dependent in this regard.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920A2","prefix":"F0920A2","text":"Does the patient require unpaid assistance with self-care tasks such as bathing, dressing, toileting, or eating/feeding?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185G7","prefix":"GG0185G7","text":"The question on the form asks about the patient's or resident's usual performance in terms of the ability to place a call in their customary manner and maintain it for 1 minute or longer. Note that this does not include the act of getting to the phone.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185J7","prefix":"GG0185J7","text":"The patient's usual performance in medication management of injectable medications assesses their ability to prepare and take all prescribed injectable medications reliably and safely. This includes the administration of the correct dosage at the appropriate times or intervals.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170C8","prefix":"GG0170C8","text":"The form is asking about the patient's ability to move from lying on their back to sitting on the side of the bed with their feet flat on the floor, without any back support. The patient's performance in this task is categorized as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175J7","prefix":"GG0175J7","text":"The form asks the patient about their ability to wheel across a street before the light turns red once they are seated in a wheelchair or scooter. The options for response are 'Motorized Wheelchair/Scooter' and 'Usual Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185D7","prefix":"GG0185D7","text":"The patient's usual performance in the ability to complete heavier periodic housework, such as doing laundry, vacuuming, and cleaning the bathroom, is evaluated to ensure they can maintain a safe home environment and not be at risk for harm within their home.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185A8","prefix":"GG0185A8","text":"The form inquires about the patient's ability to plan and prepare all aspects of a light cold meal, such as a bowl of cereal, sandwich and cold drink. The patient's performance in this area is marked as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175G7","prefix":"GG0175G7","text":"Once the patient is seated in a wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. The options are either using a motorized wheelchair/scooter or executing their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170O7","prefix":"GG0170O7","text":"The patient's usual performance is their ability to go up and down 12 steps with or without a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175D8","prefix":"GG0175D8","text":"The patient's ability to wheel for 15 minutes once seated in a manual wheelchair, without stopping or resting, for example, through a department store or supermarket, is evaluated as the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185H8","prefix":"GG0185H8","text":"The form is asking about the patient's ability to manage their oral medications. This involves the preparation and safely taking all prescribed oral medications, including the administration of the correct dosage at the appropriate times/intervals. The level of performance is marked as \"most dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125F","prefix":"GG0125F","text":"Does the patient use an assistive device such as a mechanical lift?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175D7","prefix":"GG0175D7","text":"The form asks if the patient has the ability to wheel without stopping or resting for 15 minutes once seated in a manual wheelchair, such as when navigating through a department store or supermarket. The question is about their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170G8","prefix":"GG0170G8","text":"The form asks about the patient's ability to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten the seat belt. The patient's performance in this area is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170I8","prefix":"GG0170I8","text":"The form asks about the patient's ability to walk at least 10 feet once they are standing, whether it be in a room, corridor, or a similar space. The patient's performance is rated as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0180B","prefix":"GG0180B","text":"Please ask the patient to describe at least one or two personal priorities in the area of mobility for the next six months. If the patient does not express any personal priorities in this area, please note this below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0130A7","prefix":"GG0130A7","text":"The form is asking about the patient's usual performance in eating. It refers to their ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185G8","prefix":"GG0185G8","text":"The form asks about the patient's or resident's ability to place a call in their customary manner and maintain it for 1 minute or longer. It does not include getting to the phone. The patient's performance in this area is classified as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175E8","prefix":"GG0175E8","text":"The form asks about the patient's ability to wheel across a street once seated in a wheelchair before the light turns red. The options are from most dependent to a manual wheelchair performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185B7","prefix":"GG0185B7","text":"The form asks whether the patient has the ability to plan and prepare all aspects of a light hot meal, such as heating a bowl of soup and reheating a prepared meal. The label for this question is referring to the patient's usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125L","prefix":"GG0125L","text":"Does the patient use an assistive device such as grab bars?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0905B","prefix":"F0905B","text":"Please ask the patient to describe at least one or two personal priorities in the area of living arrangements for the next six months. If the patient does not express any personal priorities in this area, kindly note this down.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170U7","prefix":"GG0170U7","text":"The form asks about the patient's usual performance in their ability to walk indoors, specifically from room to room, and around furniture and other obstacles.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185E7","prefix":"GG0185E7","text":"The form asks about the patient's usual performance in light shopping tasks. Specifically, it asks if the patient can once at the store locate and select up to five needed goods, take them to the checkout, and complete the purchasing transaction.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170P8","prefix":"GG0170P8","text":"The form inquires about the patient's ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor. The performance level selected for the patient is \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185B8","prefix":"GG0185B8","text":"The form asks about the patient's ability to plan and prepare all aspects of a light hot meal, such as heating a bowl of soup and reheating a prepared meal. It is noted that the patient's performance in this area is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125Q","prefix":"GG0125Q","text":"Does the patient use an assistive device such as a hearing aid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125ZZ","prefix":"GG0125ZZ","text":"The patient has indicated all the assistive devices they needed.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-37/GG0170N8","prefix":"GG0170N8","text":"The form inquires about the patient's ability to go up and down four steps, with or without the assistance of a rail. The performance level was noted as \"most dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0900A2","prefix":"F0900A2","text":"Please identify the patient's or resident's usual living arrangement during the past month.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident} lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30925-4","display":"Person lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident} lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30926-2","display":"Person lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident} lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30927-0","display":"Person lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident} does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30928-8","display":"Person does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident} was in a medical facility."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30929-6","display":"Person was in a medical facility."}}]},{"linkId":"Section-37/GG0170J8","prefix":"GG0170J8","text":"Once the patient is standing, they will be assessed on their ability to walk at least 50 feet and make two turns. The potential ratings for performance in this task range from 'Most Dependent' to 'Independent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130EE7","prefix":"GG0130EE7","text":"The form inquires about the patient's usual performance regarding the ability to shower or bathe themselves, including tasks such as washing, rinsing, and drying themselves. It should be noted that this does not include the act of transferring in or out of the tub or shower.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185C7","prefix":"GG0185C7","text":"The form is asking about the patient's usual performance in terms of their ability to complete light daily housework. This entails maintaining a safe home environment so that the patient is not at risk from harm within their home. Examples of such housework include tasks like wiping counter tops or doing dishes.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130EE8","prefix":"GG0130EE8","text":"The form is asking about the patient's level of ability to bathe themselves, including washing, rinsing, and drying. The question does not include the process of transferring in and out of a tub or shower. The performance level designated is \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920A1","prefix":"F0920A1","text":"Does the patient require paid assistance for self-care activities such as bathing, dressing, toileting, or eating/feeding?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170E8","prefix":"GG0170E8","text":"The form asks about the patient's ability to transfer from a bed to a chair or wheelchair. It is labeled \"Most Dependent Performance\", indicating the need for assistance with this task.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125M","prefix":"GG0125M","text":"Does the patient use an assistive device such as a transfer board?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0130B8","prefix":"GG0130B8","text":"The form asks about the patient's ability to maintain oral hygiene by using suitable items to clean their teeth and, if applicable, their ability to insert and remove dentures into and from their mouth, as well as manage denture soaking and rinsing with the use of equipment. The response category for their performance is \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125S","prefix":"GG0125S","text":"The patient uses an assistive device, specifically stair rails.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0135B","prefix":"GG0135B","text":"Please ask the patient to describe at least one or two personal priorities in the area of self-care for the next six months. If the patient does not express any personal priorities in this area, please record this information below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170P7","prefix":"GG0170P7","text":"The form asks about the patient's usual performance in the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175C7","prefix":"GG0175C7","text":"Once the patient is seated in their manual wheelchair, their usual performance indicates their ability to wheel at least 150 feet in a corridor or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920E2","prefix":"F0920E2","text":"The patient has undergone medical procedures/treatments such as changing a wound dressing or a home exercise program, for which they have not paid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185K8","prefix":"GG0185K8","text":"The form asks about the patient's simple financial management skills, such as their ability to complete financial transactions, counting coins, verifying change for a single item transaction, writing a check, using online/mobile bill pay, banking, or shopping. The patient's performance is most dependent in these areas.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125C","prefix":"GG0125C","text":"Does the patient use an assistive device such as a wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185H7","prefix":"GG0185H7","text":"The patient's usual performance in medication management, specifically for oral medications, refers to their ability to prepare and take all prescribed oral medications reliably and safely. This includes administering the correct dosage at the appropriate times or intervals.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125P","prefix":"GG0125P","text":"Does the patient use an assistive device such as glasses or contact lenses?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175I7","prefix":"GG0175I7","text":"The form asks about the patient's ability to wheel for 15 minutes without stopping or resting, such as through a department store or supermarket, while seated in a wheelchair or scooter. Does the patient typically use a motorized wheelchair or scooter for this task?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125W","prefix":"GG0125W","text":"Does the patient use an assistive device such as a glucometer?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125T","prefix":"GG0125T","text":"Does the patient use an assistive device such as a lift chair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125D","prefix":"GG0125D","text":"Does the patient use an assistive device such as a limb prosthesis?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185J8","prefix":"GG0185J8","text":"The form asks about the patient's ability to manage injectable medications. It specifically addresses whether the patient can reliably and safely prepare and take all prescribed injectable medications, including the administration of the correct dosage at the correct times/intervals. The patient's performance in this area is marked as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125V","prefix":"GG0125V","text":"Does the patient use an assistive device such as a raised toilet seat?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Y","prefix":"GG0125Y","text":"Does the patient use an assistive device such as an oxygen concentrator?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175J8","prefix":"GG0175J8","text":"The question on the form is asking about the patient's ability, once seated in a wheelchair or scooter, to wheel across a street before the traffic light turns red. The answer choices are 'Motorized Wheelchair/Scooter' and 'Most Dependent Performance.'","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185I7","prefix":"GG0185I7","text":"The form asks about the patient's ability to manage their medication, specifically regarding inhalant or mist medications. It wants to know if the patient can prepare and take all prescribed inhalant or mist medications reliably and safely, including the correct dosage at the appropriate times or intervals. It asks for information about their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125U","prefix":"GG0125U","text":"Does the patient use an assistive device such as ramps?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0180A","prefix":"GG0180A","text":"Please ask the patient to describe at least one or two personal priorities in the area of mobility for the next six months. If the patient does not express any personal priorities in this area, please note this below. The answer options would be: A) Improvement in walking, B) Ability to climb stairs, C) Independence in moving, or D) No personal priorities.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0135A","prefix":"GG0135A","text":"Please ask the patient to describe at least one or two personal priorities in the area of self-care for the next six months. If the patient does not express any personal priorities in this area, please note this in their record.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0125K","prefix":"GG0125K","text":"Does the patient use an assistive device such as an electronic bed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125H","prefix":"GG0125H","text":"Does the patient use an assistive device such as a sock aid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920C2","prefix":"F0920C2","text":"The patient requires assistance with Instrumental Activities of Daily Living (IADL), such as making meals, housekeeping, telephone, shopping, or finances, which is currently unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0130A8","prefix":"GG0130A8","text":"The question on the form assesses the patient's ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them. The performance options range from independent to most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125J","prefix":"GG0125J","text":"Does the patient use an assistive device such as a bed rail?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920G1","prefix":"F0920G1","text":"Does the patient require supervision, for example due to safety concerns, and is this supervision paid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0125O","prefix":"GG0125O","text":"Does the patient use an assistive device such as a walk-in or wheel-in shower?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125B3","prefix":"GG0125B3","text":"Does the patient use an assistive device, specifically a walker with wheels?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125G","prefix":"GG0125G","text":"Does the patient use an assistive device such as a reacher or grabber?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170F7","prefix":"GG0170F7","text":"The form asks about the patient's usual performance in terms of their ability to get on and off a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125N","prefix":"GG0125N","text":"Does the patient require an assistive device such as a shower or commode chair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125X","prefix":"GG0125X","text":"Does the patient use an assistive device such as a Continuous Positive Airway Pressure (CPAP) machine?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125C1","prefix":"GG0125C1","text":"Does the patient use an assistive device such as a manual wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170G7","prefix":"GG0170G7","text":"The patient's usual performance indicates their ability to transfer in and out of a car or van on the passenger side. This does not include their ability to open/close the door or fasten the seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125B2","prefix":"GG0125B2","text":"Does the patient use an assistive device such as a walker with a seat?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185I8","prefix":"GG0185I8","text":"The form asks about the patient's ability to manage medication, specifically inhalant or mist medications. It wants to know if the patient can reliably and safely prepare and take all prescribed inhalant/mist medications, including the administration of the correct dosage at the appropriate times and intervals. The answer choices include 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130B7","prefix":"GG0130B7","text":"The form asks about the patient's oral hygiene, specifically their ability to use suitable items to clean their teeth. It also inquires about their use of dentures, if applicable, including their ability to insert and remove the dentures from their mouth, and manage denture soaking and rinsing with the use of equipment. The section is labeled \"Usual Performance.\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125I","prefix":"GG0125I","text":"Does the patient use an assistive device such as orthotics or a brace?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Z_specify","prefix":"GG0125Z_specify","text":"Does the patient use any other type of assistive device? If so, please specify.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170A8","prefix":"GG0170A8","text":"The patient's ability to roll from lying on their back to their left and right side, and return to lying on their back is most dependent on performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130CC7","prefix":"GG0130CC7","text":"The form asks about the patient's usual performance in maintaining toileting hygiene, specifically their ability to maintain perineal/menstrual hygiene and adjust clothing before and after voiding or having a bowel movement. If the patient manages an ostomy, it also includes wiping the opening but does not include managing equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920D1","prefix":"F0920D1","text":"The form asks about the patient's method of medication administration, with options that include oral, inhaled, or injectable medications. The medication administration for the patient is paid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0125E","prefix":"GG0125E","text":"Does the patient use an assistive device, such as a specialized seating pad (for example, an air-filled, gel, or shaped form pad)?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125C2","prefix":"GG0125C2","text":"Does the patient use an assistive device such as a motorized wheelchair and/or scooter?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170L8","prefix":"GG0170L8","text":"The form asks whether the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoors or outdoors. The answer choices for the patient's performance are: Most Independent Performance, Modified Independent, Supervision or Setup, Minimal Assistance, Moderate Assistance, Maximal Assistance, and Most Dependent Performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130CC8","prefix":"GG0130CC8","text":"The form asks the patient about their toileting hygiene, specifically their ability to maintain perineal/menstrual hygiene and adjust their clothes before and after voiding or having a bowel movement. If they are managing an ostomy, they should include their ability to wipe the opening, although managing the equipment is not necessary. The performance rating is either \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185A7","prefix":"GG0185A7","text":"The patient's usual performance demonstrates the ability to plan and prepare all aspects of a light, cold meal such as a bowl of cereal, sandwich, and cold drink.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920G2","prefix":"F0920G2","text":"The form asks if the patient requires supervision due to safety concerns, and specifies if this supervision is unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920C1","prefix":"F0920C1","text":"Does the patient require paid assistance for Instrumental Activities of Daily Living (IADL), such as making meals, housekeeping, using the telephone, shopping, or managing finances?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185L7","prefix":"GG0185L7","text":"The patient's usual performance in complex financial management involves the ability to complete financial decision-making tasks such as budgeting and remembering to pay bills.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185C8","prefix":"GG0185C8","text":"The form inquires about the patient's ability to perform light daily housework in order to maintain a safe home environment such that they are not at risk from harm within their own home. Examples of this housework might include tasks like wiping countertops or doing dishes. The patient's performance is labeled as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125R","prefix":"GG0125R","text":"Does the patient use an assistive device such as a communication device?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920F2","prefix":"F0920F2","text":"Does the patient manage their own equipment, such as oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies, without any payment?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185D8","prefix":"GG0185D8","text":"The form asks about the patient's ability to complete heavier periodic housework, like doing laundry, vacuuming, and cleaning the bathroom, in order to maintain a safe home environment. It also ensures the patient is not at risk for harm within their home. The category marked is 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170B8","prefix":"GG0170B8","text":"The form for the patient includes a question labeled \"Sit to lying\". This refers to the patient's ability to move from sitting on the side of the bed to lying flat on the bed. The performance is categorized as \"Most Dependent\", meaning the patient requires substantial assistance in this task.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130D7","prefix":"GG0130D7","text":"Does the patient have the ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed? Please rate their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0190A","prefix":"GG0190A","text":"Please ask the patient to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the patient does not express any personal priorities in this area, please note this below. Answer: A","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0905A","prefix":"F0905A","text":"Please ask the patient to describe at least one or two personal priorities in the area of their living arrangements for the next six months. If the patient does not express any personal priorities in this area, please note this below. The options are - A.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0920B1","prefix":"F0920B1","text":"Does the patient require mobility assistance, such as assistance with bed mobility, transfers, ambulating, or wheeling? If yes, is this assistance paid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185L8","prefix":"GG0185L8","text":"The form indicates the patient's level of ability in complex financial management, such as completing financial decision-making tasks including budgeting and remembering to pay bills. The patient's performance is recorded as mostly dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130H8","prefix":"GG0130H8","text":"The form asks about the patient's ability to put on and take off socks, shoes, or other appropriate footwear that is necessary for safe mobility, which includes dealing with fasteners, if applicable. The patient's performance in this aspect has been rated as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175H8","prefix":"GG0175H8","text":"The form is asking about the patient's ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter. The answer choices include 'Motorized Wheelchair/Scooter' and 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170A7","prefix":"GG0170A7","text":"The form asks about the patient's usual performance when it comes to their ability to roll from lying on their back to their left and right side, and then return to lying on their back.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185F7","prefix":"GG0185F7","text":"The form asks about the patient's ability to answer a telephone call in their customary manner and maintain the call for one minute or longer. It does not include getting to the phone. The question refers to the patient's usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175I8","prefix":"GG0175I8","text":"The patient questionnaire asked, \"Once the patient is seated in a wheelchair or scooter, do they have the ability to wheel without stopping or resting for 15 minutes (for example, through a department store or supermarket)?\" The answer choices include \"Motorized Wheelchair/Scooter\" and \"Most Dependent Performance.\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0190B","prefix":"GG0190B","text":"Please ask the patient to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the patient does not express any personal priorities in this area, note it below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0925A","prefix":"F0925A","text":"Please ask the patient to describe at least one or two personal priorities for their caregiving arrangement in the next six months. If the patient does not express any personal priorities in this area, please note this below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0925B","prefix":"F0925B","text":"Please ask the patient or resident to describe at least one or two personal priorities in the area of caregiving for the next six months. If the patient or resident does not express any personal priorities in this area, please note this below. The options are:\n\nA. The patient expresses personal priorities in the area of caregiving.\nB. The patient does not express any personal priorities in the area of caregiving.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170V8","prefix":"GG0170V8","text":"The form for the patient asks about his or her ability to carry something in both hands while walking indoors, such as several dishes, a light laundry basket, or a tray with food. The patient's performance in this area is identified as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]}],"_id":"yacmJPmotkov7p3pB"} {"id":"fasi","responseType":"QuestionnaireResponse","status":"draft","authored":"2024-04-27T18:21:32.181Z","item":[{"linkId":"Section-37/GG0175A","prefix":"GG0175A","text":"Does the patient or resident use a manual wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0175F","prefix":"GG0175F","text":"Does the patient or resident use a motorized wheelchair and/or scooter?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0125B1","prefix":"GG0125B1","text":"Does the patient use an assistive device such as a standard folding walker?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170HH","prefix":"GG0170HH","text":"Does the patient or resident have the ability to walk?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No, and walking goal is not indicated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA31067-4","display":"No, and walking goal is not indicated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"No, and walking is indicated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA31068-2","display":"No, and walking goal is indicated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-6/F0900A1","prefix":"F0900A1","text":"Please identify the usual living arrangement of the patient or resident during the past three days.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident} lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30925-4","display":"Person lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident} lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30926-2","display":"Person lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident} lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30927-0","display":"Person lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident} does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30928-8","display":"Person does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident} was in a medical facility."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30929-6","display":"Person was in a medical facility."}}]},{"linkId":"Section-37/GG0125B","prefix":"GG0125B","text":"Does the patient use an assistive device such as a walker?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Z","prefix":"GG0125Z","text":"Does the patient use an assistive device other than the ones previously mentioned?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125A","prefix":"GG0125A","text":"The patient uses an assistive device, specifically a cane or a crutch.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125AA","prefix":"GG0125AA","text":"In the past month, has the patient used, or expressed or demonstrated a need for an assistive device?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}}]},{"linkId":"Section-6/F0910A","prefix":"F0910A","text":"Does the patient or resident have assistance in their home? The options are \"Yes\" or \"No\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170X7","prefix":"GG0170X7","text":"The patient's usual performance indicates their ability to walk across a street before the light turns red.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170E7","prefix":"GG0170E7","text":"The form inquires about the patient's usual performance in terms of their ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170J7","prefix":"GG0170J7","text":"Does the patient have the ability, once standing, to walk at least 50 feet and make two turns as part of their usual performance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920E1","prefix":"F0920E1","text":"Has the patient paid for medical procedures or treatments, such as changing wound dressings or home exercise programs?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920B2","prefix":"F0920B2","text":"Does the patient require mobility assistance, such as help with bed mobility, transfers, ambulating, or wheeling, and is this assistance unpaid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170K7","prefix":"GG0170K7","text":"Once the patient is standing, they should have the ability to walk at least 150 feet in a corridor or similar space. The usual performance is evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170F8","prefix":"GG0170F8","text":"The form inquires about the patient's ability to transfer to and from a toilet or commode, asking whether their performance is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170D7","prefix":"GG0170D7","text":"Does the patient typically have the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920H1","prefix":"F0920H1","text":"Does the individual advocate or facilitate the patient's participation in appropriate medical care, for example, providing transportation to or from appointments? The options for this are either paid or unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170M7","prefix":"GG0170M7","text":"The form asks about the patient's usual performance in the ability to go up and down a curb and/or up and down one step.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170W8","prefix":"GG0170W8","text":"The patient's ability to walk for 15 minutes without stopping or resting, like through a department store or supermarket, is the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170B7","prefix":"GG0170B7","text":"The form asks about the patient's usual ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130F7","prefix":"GG0130F7","text":"The form asks about the patient's usual performance in terms of their ability to dress and undress their upper body, including handling fasteners if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170X8","prefix":"GG0170X8","text":"The form asks the patient about their ability to walk across a street before the light turns red, with the most dependent performance as an answer choice.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170N7","prefix":"GG0170N7","text":"The form is asking about the patient's usual performance in regards to their ability to go up and down four steps, with or without using a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175B8","prefix":"GG0175B8","text":"Once seated in their manual wheelchair, the patient has the ability to wheel at least 50 feet and make two turns, indicating a most dependent performance level.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920F1","prefix":"F0920F1","text":"Does the patient manage their equipment, for example, oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies, and is it paid for?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920D2","prefix":"F0920D2","text":"Does the patient administer their medication themselves (for example, oral, inhaled, or injectable medications) without any paid assistance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0910B2","prefix":"F0910B2","text":"Please indicate the level of both paid and unpaid assistance in the patient's or resident's home during the past month. The level of assistance was unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No assistance received"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12345-7","display":"No assistance received"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Occasional/short-term assistance"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30934-6","display":"Occasional/short term assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Regular night-time"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30935-3","display":"Regular night-time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Regular daytime"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12164-2","display":"Regular daytime"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Around the clock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12163-4","display":"Around the clock"}}]},{"linkId":"Section-37/GG0130H7","prefix":"GG0130H7","text":"The form asks the patient to evaluate their usual performance in putting on and taking off socks, shoes, or other footwear appropriate for safe mobility. This includes handling fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170O8","prefix":"GG0170O8","text":"The form asks the patient to assess their ability to go up and down 12 steps with or without a rail, with the most dependent performance being the possible response.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130G7","prefix":"GG0130G7","text":"The form asks about the patient's usual performance in their ability to dress and undress below the waist, including fasteners, excluding footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170M8","prefix":"GG0170M8","text":"The form asks about the patient's ability to go up and down a curb and/or up and down one step. The patient's performance is most dependent in this activity.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175G8","prefix":"GG0175G8","text":"Once seated in their motorized wheelchair or scooter, the patient has the ability to wheel at least 50 feet and make two turns. However, their performance indicates that they are most dependent on this form of mobility.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920H2","prefix":"F0920H2","text":"Does the person facilitate or advocate for the patient's participation in appropriate medical care, for instance, by transporting them to or from appointments, without any charge?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0910B1","prefix":"F0910B1","text":"Please indicate the level of both paid and unpaid assistance in the patient's or resident's home during the past month. The choices are \"Paid\", \"Unpaid\", or \"Both Paid and Unpaid\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No assistance received"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12345-7","display":"No assistance received"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Occasional/short-term assistance"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30934-6","display":"Occasional/short term assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Regular night-time"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30935-3","display":"Regular night-time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Regular daytime"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12164-2","display":"Regular daytime"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Around the clock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12163-4","display":"Around the clock"}}]},{"linkId":"Section-37/GG0175B7","prefix":"GG0175B7","text":"The form asks about the patient's ability to wheel at least 50 feet and make two turns once seated in a manual wheelchair, assessing their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170I7","prefix":"GG0170I7","text":"The form asks about the patient's usual performance in terms of their ability to walk at least 10 feet once standing, whether it be in a room, corridor, or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170L7","prefix":"GG0170L7","text":"The form asks about the patient's usual performance in the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, both indoors and outdoors.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170U8","prefix":"GG0170U8","text":"The form asks about the patient's ability to walk from one room to another, maneuver around furniture, and navigate other obstacles indoors. The label classifies the patient's performance as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175C8","prefix":"GG0175C8","text":"Once the patient is seated in the wheelchair, they should have the ability to wheel at least 150 feet in a corridor or similar space. The choices for this ability are with a manual wheelchair or indicating the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185F8","prefix":"GG0185F8","text":"The form asks about the patient's ability to answer a telephone call in their customary manner and maintain it for 1 minute or longer. This does not include getting to the phone. The label for the most dependent performance is used.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185K7","prefix":"GG0185K7","text":"The patient's usual performance in simple financial management includes the ability to complete financial transactions such as counting coins, verifying change for a single item transaction, writing a check, online/mobile bill pay, banking, or shopping.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175E7","prefix":"GG0175E7","text":"The form is asking about the patient's ability to wheel across a street using a manual wheelchair before the light turns red. The patient usually performs this task with their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130F8","prefix":"GG0130F8","text":"The form asks about the patient's ability to dress and undress above the waist, including dealing with fasteners if applicable, and the patient's most dependent performance is being evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175H7","prefix":"GG0175H7","text":"Once the patient is seated in the wheelchair or scooter, does he or she have the ability to wheel at least 150 feet in a corridor or similar space? The options are: Motorized Wheelchair/Scooter or Usual Performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170C7","prefix":"GG0170C7","text":"The form asks about the patient's usual performance in the ability to move from lying on their back to sitting on the side of the bed with their feet flat on the floor, and without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130G8","prefix":"GG0130G8","text":"The form asks about the patient's ability to dress and undress below the waist, including handling fasteners, but not including footwear. It indicates that the patient's performance in this area is mostly dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130D8","prefix":"GG0130D8","text":"The form asks about the patient's ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed. The performance level indicated is \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170K8","prefix":"GG0170K8","text":"The form asks if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The performance level is gauged as 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185E8","prefix":"GG0185E8","text":"The patient's performance level in light shopping is at its most dependent. Once at the store, they can locate and select up to five needed goods, take them to the checkout, and complete the purchasing transaction.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170W7","prefix":"GG0170W7","text":"Does the patient have the ability to walk for 15 minutes without stopping or resting, such as through a department store or supermarket, as part of their usual performance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170V7","prefix":"GG0170V7","text":"The form asks whether the patient has the ability to carry something in both hands, such as several dishes, a light laundry basket, or a tray with food, while walking indoors. The category for this question is 'Usual Performance.'","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170D8","prefix":"GG0170D8","text":"The form asks about the patient's ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. The patient's performance is most dependent in this regard.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920A2","prefix":"F0920A2","text":"Does the patient require unpaid assistance with self-care tasks such as bathing, dressing, toileting, or eating/feeding?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185G7","prefix":"GG0185G7","text":"The question on the form asks about the patient's or resident's usual performance in terms of the ability to place a call in their customary manner and maintain it for 1 minute or longer. Note that this does not include the act of getting to the phone.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185J7","prefix":"GG0185J7","text":"The patient's usual performance in medication management of injectable medications assesses their ability to prepare and take all prescribed injectable medications reliably and safely. This includes the administration of the correct dosage at the appropriate times or intervals.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170C8","prefix":"GG0170C8","text":"The form is asking about the patient's ability to move from lying on their back to sitting on the side of the bed with their feet flat on the floor, without any back support. The patient's performance in this task is categorized as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175J7","prefix":"GG0175J7","text":"The form asks the patient about their ability to wheel across a street before the light turns red once they are seated in a wheelchair or scooter. The options for response are 'Motorized Wheelchair/Scooter' and 'Usual Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185D7","prefix":"GG0185D7","text":"The patient's usual performance in the ability to complete heavier periodic housework, such as doing laundry, vacuuming, and cleaning the bathroom, is evaluated to ensure they can maintain a safe home environment and not be at risk for harm within their home.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185A8","prefix":"GG0185A8","text":"The form inquires about the patient's ability to plan and prepare all aspects of a light cold meal, such as a bowl of cereal, sandwich and cold drink. The patient's performance in this area is marked as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175G7","prefix":"GG0175G7","text":"Once the patient is seated in a wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. The options are either using a motorized wheelchair/scooter or executing their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170O7","prefix":"GG0170O7","text":"The patient's usual performance is their ability to go up and down 12 steps with or without a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175D8","prefix":"GG0175D8","text":"The patient's ability to wheel for 15 minutes once seated in a manual wheelchair, without stopping or resting, for example, through a department store or supermarket, is evaluated as the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185H8","prefix":"GG0185H8","text":"The form is asking about the patient's ability to manage their oral medications. This involves the preparation and safely taking all prescribed oral medications, including the administration of the correct dosage at the appropriate times/intervals. The level of performance is marked as \"most dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125F","prefix":"GG0125F","text":"Does the patient use an assistive device such as a mechanical lift?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175D7","prefix":"GG0175D7","text":"The form asks if the patient has the ability to wheel without stopping or resting for 15 minutes once seated in a manual wheelchair, such as when navigating through a department store or supermarket. The question is about their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170G8","prefix":"GG0170G8","text":"The form asks about the patient's ability to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten the seat belt. The patient's performance in this area is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170I8","prefix":"GG0170I8","text":"The form asks about the patient's ability to walk at least 10 feet once they are standing, whether it be in a room, corridor, or a similar space. The patient's performance is rated as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0180B","prefix":"GG0180B","text":"Please ask the patient to describe at least one or two personal priorities in the area of mobility for the next six months. If the patient does not express any personal priorities in this area, please note this below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0130A7","prefix":"GG0130A7","text":"The form is asking about the patient's usual performance in eating. It refers to their ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185G8","prefix":"GG0185G8","text":"The form asks about the patient's or resident's ability to place a call in their customary manner and maintain it for 1 minute or longer. It does not include getting to the phone. The patient's performance in this area is classified as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175E8","prefix":"GG0175E8","text":"The form asks about the patient's ability to wheel across a street once seated in a wheelchair before the light turns red. The options are from most dependent to a manual wheelchair performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185B7","prefix":"GG0185B7","text":"The form asks whether the patient has the ability to plan and prepare all aspects of a light hot meal, such as heating a bowl of soup and reheating a prepared meal. The label for this question is referring to the patient's usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125L","prefix":"GG0125L","text":"Does the patient use an assistive device such as grab bars?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0905B","prefix":"F0905B","text":"Please ask the patient to describe at least one or two personal priorities in the area of living arrangements for the next six months. If the patient does not express any personal priorities in this area, kindly note this down.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170U7","prefix":"GG0170U7","text":"The form asks about the patient's usual performance in their ability to walk indoors, specifically from room to room, and around furniture and other obstacles.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185E7","prefix":"GG0185E7","text":"The form asks about the patient's usual performance in light shopping tasks. Specifically, it asks if the patient can once at the store locate and select up to five needed goods, take them to the checkout, and complete the purchasing transaction.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170P8","prefix":"GG0170P8","text":"The form inquires about the patient's ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor. The performance level selected for the patient is \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185B8","prefix":"GG0185B8","text":"The form asks about the patient's ability to plan and prepare all aspects of a light hot meal, such as heating a bowl of soup and reheating a prepared meal. It is noted that the patient's performance in this area is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125Q","prefix":"GG0125Q","text":"Does the patient use an assistive device such as a hearing aid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125ZZ","prefix":"GG0125ZZ","text":"The patient has indicated all the assistive devices they needed.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-37/GG0170N8","prefix":"GG0170N8","text":"The form inquires about the patient's ability to go up and down four steps, with or without the assistance of a rail. The performance level was noted as \"most dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0900A2","prefix":"F0900A2","text":"Please identify the patient's or resident's usual living arrangement during the past month.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident} lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30925-4","display":"Person lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident} lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30926-2","display":"Person lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident} lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30927-0","display":"Person lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident} does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30928-8","display":"Person does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident} was in a medical facility."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30929-6","display":"Person was in a medical facility."}}]},{"linkId":"Section-37/GG0170J8","prefix":"GG0170J8","text":"Once the patient is standing, they will be assessed on their ability to walk at least 50 feet and make two turns. The potential ratings for performance in this task range from 'Most Dependent' to 'Independent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130EE7","prefix":"GG0130EE7","text":"The form inquires about the patient's usual performance regarding the ability to shower or bathe themselves, including tasks such as washing, rinsing, and drying themselves. It should be noted that this does not include the act of transferring in or out of the tub or shower.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185C7","prefix":"GG0185C7","text":"The form is asking about the patient's usual performance in terms of their ability to complete light daily housework. This entails maintaining a safe home environment so that the patient is not at risk from harm within their home. Examples of such housework include tasks like wiping counter tops or doing dishes.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130EE8","prefix":"GG0130EE8","text":"The form is asking about the patient's level of ability to bathe themselves, including washing, rinsing, and drying. The question does not include the process of transferring in and out of a tub or shower. The performance level designated is \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920A1","prefix":"F0920A1","text":"Does the patient require paid assistance for self-care activities such as bathing, dressing, toileting, or eating/feeding?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170E8","prefix":"GG0170E8","text":"The form asks about the patient's ability to transfer from a bed to a chair or wheelchair. It is labeled \"Most Dependent Performance\", indicating the need for assistance with this task.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125M","prefix":"GG0125M","text":"Does the patient use an assistive device such as a transfer board?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0130B8","prefix":"GG0130B8","text":"The form asks about the patient's ability to maintain oral hygiene by using suitable items to clean their teeth and, if applicable, their ability to insert and remove dentures into and from their mouth, as well as manage denture soaking and rinsing with the use of equipment. The response category for their performance is \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125S","prefix":"GG0125S","text":"The patient uses an assistive device, specifically stair rails.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0135B","prefix":"GG0135B","text":"Please ask the patient to describe at least one or two personal priorities in the area of self-care for the next six months. If the patient does not express any personal priorities in this area, please record this information below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170P7","prefix":"GG0170P7","text":"The form asks about the patient's usual performance in the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175C7","prefix":"GG0175C7","text":"Once the patient is seated in their manual wheelchair, their usual performance indicates their ability to wheel at least 150 feet in a corridor or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920E2","prefix":"F0920E2","text":"The patient has undergone medical procedures/treatments such as changing a wound dressing or a home exercise program, for which they have not paid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185K8","prefix":"GG0185K8","text":"The form asks about the patient's simple financial management skills, such as their ability to complete financial transactions, counting coins, verifying change for a single item transaction, writing a check, using online/mobile bill pay, banking, or shopping. The patient's performance is most dependent in these areas.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125C","prefix":"GG0125C","text":"Does the patient use an assistive device such as a wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185H7","prefix":"GG0185H7","text":"The patient's usual performance in medication management, specifically for oral medications, refers to their ability to prepare and take all prescribed oral medications reliably and safely. This includes administering the correct dosage at the appropriate times or intervals.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125P","prefix":"GG0125P","text":"Does the patient use an assistive device such as glasses or contact lenses?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175I7","prefix":"GG0175I7","text":"The form asks about the patient's ability to wheel for 15 minutes without stopping or resting, such as through a department store or supermarket, while seated in a wheelchair or scooter. Does the patient typically use a motorized wheelchair or scooter for this task?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125W","prefix":"GG0125W","text":"Does the patient use an assistive device such as a glucometer?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125T","prefix":"GG0125T","text":"Does the patient use an assistive device such as a lift chair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125D","prefix":"GG0125D","text":"Does the patient use an assistive device such as a limb prosthesis?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185J8","prefix":"GG0185J8","text":"The form asks about the patient's ability to manage injectable medications. It specifically addresses whether the patient can reliably and safely prepare and take all prescribed injectable medications, including the administration of the correct dosage at the correct times/intervals. The patient's performance in this area is marked as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125V","prefix":"GG0125V","text":"Does the patient use an assistive device such as a raised toilet seat?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Y","prefix":"GG0125Y","text":"Does the patient use an assistive device such as an oxygen concentrator?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175J8","prefix":"GG0175J8","text":"The question on the form is asking about the patient's ability, once seated in a wheelchair or scooter, to wheel across a street before the traffic light turns red. The answer choices are 'Motorized Wheelchair/Scooter' and 'Most Dependent Performance.'","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185I7","prefix":"GG0185I7","text":"The form asks about the patient's ability to manage their medication, specifically regarding inhalant or mist medications. It wants to know if the patient can prepare and take all prescribed inhalant or mist medications reliably and safely, including the correct dosage at the appropriate times or intervals. It asks for information about their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125U","prefix":"GG0125U","text":"Does the patient use an assistive device such as ramps?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0180A","prefix":"GG0180A","text":"Please ask the patient to describe at least one or two personal priorities in the area of mobility for the next six months. If the patient does not express any personal priorities in this area, please note this below. The answer options would be: A) Improvement in walking, B) Ability to climb stairs, C) Independence in moving, or D) No personal priorities.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0135A","prefix":"GG0135A","text":"Please ask the patient to describe at least one or two personal priorities in the area of self-care for the next six months. If the patient does not express any personal priorities in this area, please note this in their record.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0125K","prefix":"GG0125K","text":"Does the patient use an assistive device such as an electronic bed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125H","prefix":"GG0125H","text":"Does the patient use an assistive device such as a sock aid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920C2","prefix":"F0920C2","text":"The patient requires assistance with Instrumental Activities of Daily Living (IADL), such as making meals, housekeeping, telephone, shopping, or finances, which is currently unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0130A8","prefix":"GG0130A8","text":"The question on the form assesses the patient's ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them. The performance options range from independent to most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125J","prefix":"GG0125J","text":"Does the patient use an assistive device such as a bed rail?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920G1","prefix":"F0920G1","text":"Does the patient require supervision, for example due to safety concerns, and is this supervision paid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0125O","prefix":"GG0125O","text":"Does the patient use an assistive device such as a walk-in or wheel-in shower?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125B3","prefix":"GG0125B3","text":"Does the patient use an assistive device, specifically a walker with wheels?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125G","prefix":"GG0125G","text":"Does the patient use an assistive device such as a reacher or grabber?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170F7","prefix":"GG0170F7","text":"The form asks about the patient's usual performance in terms of their ability to get on and off a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125N","prefix":"GG0125N","text":"Does the patient require an assistive device such as a shower or commode chair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125X","prefix":"GG0125X","text":"Does the patient use an assistive device such as a Continuous Positive Airway Pressure (CPAP) machine?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125C1","prefix":"GG0125C1","text":"Does the patient use an assistive device such as a manual wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170G7","prefix":"GG0170G7","text":"The patient's usual performance indicates their ability to transfer in and out of a car or van on the passenger side. This does not include their ability to open/close the door or fasten the seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125B2","prefix":"GG0125B2","text":"Does the patient use an assistive device such as a walker with a seat?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185I8","prefix":"GG0185I8","text":"The form asks about the patient's ability to manage medication, specifically inhalant or mist medications. It wants to know if the patient can reliably and safely prepare and take all prescribed inhalant/mist medications, including the administration of the correct dosage at the appropriate times and intervals. The answer choices include 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130B7","prefix":"GG0130B7","text":"The form asks about the patient's oral hygiene, specifically their ability to use suitable items to clean their teeth. It also inquires about their use of dentures, if applicable, including their ability to insert and remove the dentures from their mouth, and manage denture soaking and rinsing with the use of equipment. The section is labeled \"Usual Performance.\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125I","prefix":"GG0125I","text":"Does the patient use an assistive device such as orthotics or a brace?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Z_specify","prefix":"GG0125Z_specify","text":"Does the patient use any other type of assistive device? If so, please specify.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170A8","prefix":"GG0170A8","text":"The patient's ability to roll from lying on their back to their left and right side, and return to lying on their back is most dependent on performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130CC7","prefix":"GG0130CC7","text":"The form asks about the patient's usual performance in maintaining toileting hygiene, specifically their ability to maintain perineal/menstrual hygiene and adjust clothing before and after voiding or having a bowel movement. If the patient manages an ostomy, it also includes wiping the opening but does not include managing equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920D1","prefix":"F0920D1","text":"The form asks about the patient's method of medication administration, with options that include oral, inhaled, or injectable medications. The medication administration for the patient is paid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0125E","prefix":"GG0125E","text":"Does the patient use an assistive device, such as a specialized seating pad (for example, an air-filled, gel, or shaped form pad)?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125C2","prefix":"GG0125C2","text":"Does the patient use an assistive device such as a motorized wheelchair and/or scooter?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170L8","prefix":"GG0170L8","text":"The form asks whether the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoors or outdoors. The answer choices for the patient's performance are: Most Independent Performance, Modified Independent, Supervision or Setup, Minimal Assistance, Moderate Assistance, Maximal Assistance, and Most Dependent Performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130CC8","prefix":"GG0130CC8","text":"The form asks the patient about their toileting hygiene, specifically their ability to maintain perineal/menstrual hygiene and adjust their clothes before and after voiding or having a bowel movement. If they are managing an ostomy, they should include their ability to wipe the opening, although managing the equipment is not necessary. The performance rating is either \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185A7","prefix":"GG0185A7","text":"The patient's usual performance demonstrates the ability to plan and prepare all aspects of a light, cold meal such as a bowl of cereal, sandwich, and cold drink.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920G2","prefix":"F0920G2","text":"The form asks if the patient requires supervision due to safety concerns, and specifies if this supervision is unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920C1","prefix":"F0920C1","text":"Does the patient require paid assistance for Instrumental Activities of Daily Living (IADL), such as making meals, housekeeping, using the telephone, shopping, or managing finances?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185L7","prefix":"GG0185L7","text":"The patient's usual performance in complex financial management involves the ability to complete financial decision-making tasks such as budgeting and remembering to pay bills.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185C8","prefix":"GG0185C8","text":"The form inquires about the patient's ability to perform light daily housework in order to maintain a safe home environment such that they are not at risk from harm within their own home. Examples of this housework might include tasks like wiping countertops or doing dishes. The patient's performance is labeled as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125R","prefix":"GG0125R","text":"Does the patient use an assistive device such as a communication device?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920F2","prefix":"F0920F2","text":"Does the patient manage their own equipment, such as oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies, without any payment?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185D8","prefix":"GG0185D8","text":"The form asks about the patient's ability to complete heavier periodic housework, like doing laundry, vacuuming, and cleaning the bathroom, in order to maintain a safe home environment. It also ensures the patient is not at risk for harm within their home. The category marked is 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170B8","prefix":"GG0170B8","text":"The form for the patient includes a question labeled \"Sit to lying\". This refers to the patient's ability to move from sitting on the side of the bed to lying flat on the bed. The performance is categorized as \"Most Dependent\", meaning the patient requires substantial assistance in this task.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130D7","prefix":"GG0130D7","text":"Does the patient have the ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed? Please rate their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0190A","prefix":"GG0190A","text":"Please ask the patient to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the patient does not express any personal priorities in this area, please note this below. Answer: A","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0905A","prefix":"F0905A","text":"Please ask the patient to describe at least one or two personal priorities in the area of their living arrangements for the next six months. If the patient does not express any personal priorities in this area, please note this below. The options are - A.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0920B1","prefix":"F0920B1","text":"Does the patient require mobility assistance, such as assistance with bed mobility, transfers, ambulating, or wheeling? If yes, is this assistance paid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185L8","prefix":"GG0185L8","text":"The form indicates the patient's level of ability in complex financial management, such as completing financial decision-making tasks including budgeting and remembering to pay bills. The patient's performance is recorded as mostly dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130H8","prefix":"GG0130H8","text":"The form asks about the patient's ability to put on and take off socks, shoes, or other appropriate footwear that is necessary for safe mobility, which includes dealing with fasteners, if applicable. The patient's performance in this aspect has been rated as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175H8","prefix":"GG0175H8","text":"The form is asking about the patient's ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter. The answer choices include 'Motorized Wheelchair/Scooter' and 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170A7","prefix":"GG0170A7","text":"The form asks about the patient's usual performance when it comes to their ability to roll from lying on their back to their left and right side, and then return to lying on their back.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185F7","prefix":"GG0185F7","text":"The form asks about the patient's ability to answer a telephone call in their customary manner and maintain the call for one minute or longer. It does not include getting to the phone. The question refers to the patient's usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175I8","prefix":"GG0175I8","text":"The patient questionnaire asked, \"Once the patient is seated in a wheelchair or scooter, do they have the ability to wheel without stopping or resting for 15 minutes (for example, through a department store or supermarket)?\" The answer choices include \"Motorized Wheelchair/Scooter\" and \"Most Dependent Performance.\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0190B","prefix":"GG0190B","text":"Please ask the patient to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the patient does not express any personal priorities in this area, note it below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0925A","prefix":"F0925A","text":"Please ask the patient to describe at least one or two personal priorities for their caregiving arrangement in the next six months. If the patient does not express any personal priorities in this area, please note this below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0925B","prefix":"F0925B","text":"Please ask the patient or resident to describe at least one or two personal priorities in the area of caregiving for the next six months. If the patient or resident does not express any personal priorities in this area, please note this below. The options are:\n\nA. The patient expresses personal priorities in the area of caregiving.\nB. The patient does not express any personal priorities in the area of caregiving.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170V8","prefix":"GG0170V8","text":"The form for the patient asks about his or her ability to carry something in both hands while walking indoors, such as several dishes, a light laundry basket, or a tray with food. The patient's performance in this area is identified as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]}],"_id":"z8f4L9DpyGhXuQ3Xv"} {"id":"fasi","responseType":"QuestionnaireResponse","status":"draft","authored":"2024-04-27T18:21:32.181Z","item":[{"linkId":"Section-37/GG0175A","prefix":"GG0175A","text":"Does the patient or resident use a manual wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0175F","prefix":"GG0175F","text":"Does the patient or resident use a motorized wheelchair and/or scooter?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0125B1","prefix":"GG0125B1","text":"Does the patient use an assistive device such as a standard folding walker?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170HH","prefix":"GG0170HH","text":"Does the patient or resident have the ability to walk?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No, and walking goal is not indicated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA31067-4","display":"No, and walking goal is not indicated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"No, and walking is indicated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA31068-2","display":"No, and walking goal is indicated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-6/F0900A1","prefix":"F0900A1","text":"Please identify the usual living arrangement of the patient or resident during the past three days.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident} lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30925-4","display":"Person lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident} lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30926-2","display":"Person lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident} lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30927-0","display":"Person lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident} does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30928-8","display":"Person does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident} was in a medical facility."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30929-6","display":"Person was in a medical facility."}}]},{"linkId":"Section-37/GG0125B","prefix":"GG0125B","text":"Does the patient use an assistive device such as a walker?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Z","prefix":"GG0125Z","text":"Does the patient use an assistive device other than the ones previously mentioned?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125A","prefix":"GG0125A","text":"The patient uses an assistive device, specifically a cane or a crutch.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125AA","prefix":"GG0125AA","text":"In the past month, has the patient used, or expressed or demonstrated a need for an assistive device?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}}]},{"linkId":"Section-6/F0910A","prefix":"F0910A","text":"Does the patient or resident have assistance in their home? The options are \"Yes\" or \"No\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170X7","prefix":"GG0170X7","text":"The patient's usual performance indicates their ability to walk across a street before the light turns red.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170E7","prefix":"GG0170E7","text":"The form inquires about the patient's usual performance in terms of their ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170J7","prefix":"GG0170J7","text":"Does the patient have the ability, once standing, to walk at least 50 feet and make two turns as part of their usual performance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920E1","prefix":"F0920E1","text":"Has the patient paid for medical procedures or treatments, such as changing wound dressings or home exercise programs?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920B2","prefix":"F0920B2","text":"Does the patient require mobility assistance, such as help with bed mobility, transfers, ambulating, or wheeling, and is this assistance unpaid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170K7","prefix":"GG0170K7","text":"Once the patient is standing, they should have the ability to walk at least 150 feet in a corridor or similar space. The usual performance is evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170F8","prefix":"GG0170F8","text":"The form inquires about the patient's ability to transfer to and from a toilet or commode, asking whether their performance is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170D7","prefix":"GG0170D7","text":"Does the patient typically have the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920H1","prefix":"F0920H1","text":"Does the individual advocate or facilitate the patient's participation in appropriate medical care, for example, providing transportation to or from appointments? The options for this are either paid or unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170M7","prefix":"GG0170M7","text":"The form asks about the patient's usual performance in the ability to go up and down a curb and/or up and down one step.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170W8","prefix":"GG0170W8","text":"The patient's ability to walk for 15 minutes without stopping or resting, like through a department store or supermarket, is the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170B7","prefix":"GG0170B7","text":"The form asks about the patient's usual ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130F7","prefix":"GG0130F7","text":"The form asks about the patient's usual performance in terms of their ability to dress and undress their upper body, including handling fasteners if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170X8","prefix":"GG0170X8","text":"The form asks the patient about their ability to walk across a street before the light turns red, with the most dependent performance as an answer choice.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170N7","prefix":"GG0170N7","text":"The form is asking about the patient's usual performance in regards to their ability to go up and down four steps, with or without using a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175B8","prefix":"GG0175B8","text":"Once seated in their manual wheelchair, the patient has the ability to wheel at least 50 feet and make two turns, indicating a most dependent performance level.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920F1","prefix":"F0920F1","text":"Does the patient manage their equipment, for example, oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies, and is it paid for?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920D2","prefix":"F0920D2","text":"Does the patient administer their medication themselves (for example, oral, inhaled, or injectable medications) without any paid assistance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0910B2","prefix":"F0910B2","text":"Please indicate the level of both paid and unpaid assistance in the patient's or resident's home during the past month. The level of assistance was unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No assistance received"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12345-7","display":"No assistance received"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Occasional/short-term assistance"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30934-6","display":"Occasional/short term assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Regular night-time"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30935-3","display":"Regular night-time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Regular daytime"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12164-2","display":"Regular daytime"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Around the clock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12163-4","display":"Around the clock"}}]},{"linkId":"Section-37/GG0130H7","prefix":"GG0130H7","text":"The form asks the patient to evaluate their usual performance in putting on and taking off socks, shoes, or other footwear appropriate for safe mobility. This includes handling fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170O8","prefix":"GG0170O8","text":"The form asks the patient to assess their ability to go up and down 12 steps with or without a rail, with the most dependent performance being the possible response.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130G7","prefix":"GG0130G7","text":"The form asks about the patient's usual performance in their ability to dress and undress below the waist, including fasteners, excluding footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170M8","prefix":"GG0170M8","text":"The form asks about the patient's ability to go up and down a curb and/or up and down one step. The patient's performance is most dependent in this activity.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175G8","prefix":"GG0175G8","text":"Once seated in their motorized wheelchair or scooter, the patient has the ability to wheel at least 50 feet and make two turns. However, their performance indicates that they are most dependent on this form of mobility.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920H2","prefix":"F0920H2","text":"Does the person facilitate or advocate for the patient's participation in appropriate medical care, for instance, by transporting them to or from appointments, without any charge?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0910B1","prefix":"F0910B1","text":"Please indicate the level of both paid and unpaid assistance in the patient's or resident's home during the past month. The choices are \"Paid\", \"Unpaid\", or \"Both Paid and Unpaid\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No assistance received"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12345-7","display":"No assistance received"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Occasional/short-term assistance"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30934-6","display":"Occasional/short term assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Regular night-time"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30935-3","display":"Regular night-time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Regular daytime"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12164-2","display":"Regular daytime"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Around the clock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12163-4","display":"Around the clock"}}]},{"linkId":"Section-37/GG0175B7","prefix":"GG0175B7","text":"The form asks about the patient's ability to wheel at least 50 feet and make two turns once seated in a manual wheelchair, assessing their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170I7","prefix":"GG0170I7","text":"The form asks about the patient's usual performance in terms of their ability to walk at least 10 feet once standing, whether it be in a room, corridor, or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170L7","prefix":"GG0170L7","text":"The form asks about the patient's usual performance in the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, both indoors and outdoors.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170U8","prefix":"GG0170U8","text":"The form asks about the patient's ability to walk from one room to another, maneuver around furniture, and navigate other obstacles indoors. The label classifies the patient's performance as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175C8","prefix":"GG0175C8","text":"Once the patient is seated in the wheelchair, they should have the ability to wheel at least 150 feet in a corridor or similar space. The choices for this ability are with a manual wheelchair or indicating the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185F8","prefix":"GG0185F8","text":"The form asks about the patient's ability to answer a telephone call in their customary manner and maintain it for 1 minute or longer. This does not include getting to the phone. The label for the most dependent performance is used.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185K7","prefix":"GG0185K7","text":"The patient's usual performance in simple financial management includes the ability to complete financial transactions such as counting coins, verifying change for a single item transaction, writing a check, online/mobile bill pay, banking, or shopping.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175E7","prefix":"GG0175E7","text":"The form is asking about the patient's ability to wheel across a street using a manual wheelchair before the light turns red. The patient usually performs this task with their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130F8","prefix":"GG0130F8","text":"The form asks about the patient's ability to dress and undress above the waist, including dealing with fasteners if applicable, and the patient's most dependent performance is being evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175H7","prefix":"GG0175H7","text":"Once the patient is seated in the wheelchair or scooter, does he or she have the ability to wheel at least 150 feet in a corridor or similar space? The options are: Motorized Wheelchair/Scooter or Usual Performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170C7","prefix":"GG0170C7","text":"The form asks about the patient's usual performance in the ability to move from lying on their back to sitting on the side of the bed with their feet flat on the floor, and without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130G8","prefix":"GG0130G8","text":"The form asks about the patient's ability to dress and undress below the waist, including handling fasteners, but not including footwear. It indicates that the patient's performance in this area is mostly dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130D8","prefix":"GG0130D8","text":"The form asks about the patient's ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed. The performance level indicated is \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170K8","prefix":"GG0170K8","text":"The form asks if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The performance level is gauged as 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185E8","prefix":"GG0185E8","text":"The patient's performance level in light shopping is at its most dependent. Once at the store, they can locate and select up to five needed goods, take them to the checkout, and complete the purchasing transaction.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170W7","prefix":"GG0170W7","text":"Does the patient have the ability to walk for 15 minutes without stopping or resting, such as through a department store or supermarket, as part of their usual performance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170V7","prefix":"GG0170V7","text":"The form asks whether the patient has the ability to carry something in both hands, such as several dishes, a light laundry basket, or a tray with food, while walking indoors. The category for this question is 'Usual Performance.'","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170D8","prefix":"GG0170D8","text":"The form asks about the patient's ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. The patient's performance is most dependent in this regard.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920A2","prefix":"F0920A2","text":"Does the patient require unpaid assistance with self-care tasks such as bathing, dressing, toileting, or eating/feeding?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185G7","prefix":"GG0185G7","text":"The question on the form asks about the patient's or resident's usual performance in terms of the ability to place a call in their customary manner and maintain it for 1 minute or longer. Note that this does not include the act of getting to the phone.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185J7","prefix":"GG0185J7","text":"The patient's usual performance in medication management of injectable medications assesses their ability to prepare and take all prescribed injectable medications reliably and safely. This includes the administration of the correct dosage at the appropriate times or intervals.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170C8","prefix":"GG0170C8","text":"The form is asking about the patient's ability to move from lying on their back to sitting on the side of the bed with their feet flat on the floor, without any back support. The patient's performance in this task is categorized as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175J7","prefix":"GG0175J7","text":"The form asks the patient about their ability to wheel across a street before the light turns red once they are seated in a wheelchair or scooter. The options for response are 'Motorized Wheelchair/Scooter' and 'Usual Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185D7","prefix":"GG0185D7","text":"The patient's usual performance in the ability to complete heavier periodic housework, such as doing laundry, vacuuming, and cleaning the bathroom, is evaluated to ensure they can maintain a safe home environment and not be at risk for harm within their home.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185A8","prefix":"GG0185A8","text":"The form inquires about the patient's ability to plan and prepare all aspects of a light cold meal, such as a bowl of cereal, sandwich and cold drink. The patient's performance in this area is marked as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175G7","prefix":"GG0175G7","text":"Once the patient is seated in a wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. The options are either using a motorized wheelchair/scooter or executing their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170O7","prefix":"GG0170O7","text":"The patient's usual performance is their ability to go up and down 12 steps with or without a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175D8","prefix":"GG0175D8","text":"The patient's ability to wheel for 15 minutes once seated in a manual wheelchair, without stopping or resting, for example, through a department store or supermarket, is evaluated as the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185H8","prefix":"GG0185H8","text":"The form is asking about the patient's ability to manage their oral medications. This involves the preparation and safely taking all prescribed oral medications, including the administration of the correct dosage at the appropriate times/intervals. The level of performance is marked as \"most dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125F","prefix":"GG0125F","text":"Does the patient use an assistive device such as a mechanical lift?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175D7","prefix":"GG0175D7","text":"The form asks if the patient has the ability to wheel without stopping or resting for 15 minutes once seated in a manual wheelchair, such as when navigating through a department store or supermarket. The question is about their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170G8","prefix":"GG0170G8","text":"The form asks about the patient's ability to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten the seat belt. The patient's performance in this area is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170I8","prefix":"GG0170I8","text":"The form asks about the patient's ability to walk at least 10 feet once they are standing, whether it be in a room, corridor, or a similar space. The patient's performance is rated as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0180B","prefix":"GG0180B","text":"Please ask the patient to describe at least one or two personal priorities in the area of mobility for the next six months. If the patient does not express any personal priorities in this area, please note this below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0130A7","prefix":"GG0130A7","text":"The form is asking about the patient's usual performance in eating. It refers to their ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185G8","prefix":"GG0185G8","text":"The form asks about the patient's or resident's ability to place a call in their customary manner and maintain it for 1 minute or longer. It does not include getting to the phone. The patient's performance in this area is classified as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175E8","prefix":"GG0175E8","text":"The form asks about the patient's ability to wheel across a street once seated in a wheelchair before the light turns red. The options are from most dependent to a manual wheelchair performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185B7","prefix":"GG0185B7","text":"The form asks whether the patient has the ability to plan and prepare all aspects of a light hot meal, such as heating a bowl of soup and reheating a prepared meal. The label for this question is referring to the patient's usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125L","prefix":"GG0125L","text":"Does the patient use an assistive device such as grab bars?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0905B","prefix":"F0905B","text":"Please ask the patient to describe at least one or two personal priorities in the area of living arrangements for the next six months. If the patient does not express any personal priorities in this area, kindly note this down.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170U7","prefix":"GG0170U7","text":"The form asks about the patient's usual performance in their ability to walk indoors, specifically from room to room, and around furniture and other obstacles.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185E7","prefix":"GG0185E7","text":"The form asks about the patient's usual performance in light shopping tasks. Specifically, it asks if the patient can once at the store locate and select up to five needed goods, take them to the checkout, and complete the purchasing transaction.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170P8","prefix":"GG0170P8","text":"The form inquires about the patient's ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor. The performance level selected for the patient is \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185B8","prefix":"GG0185B8","text":"The form asks about the patient's ability to plan and prepare all aspects of a light hot meal, such as heating a bowl of soup and reheating a prepared meal. It is noted that the patient's performance in this area is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125Q","prefix":"GG0125Q","text":"Does the patient use an assistive device such as a hearing aid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125ZZ","prefix":"GG0125ZZ","text":"The patient has indicated all the assistive devices they needed.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-37/GG0170N8","prefix":"GG0170N8","text":"The form inquires about the patient's ability to go up and down four steps, with or without the assistance of a rail. The performance level was noted as \"most dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0900A2","prefix":"F0900A2","text":"Please identify the patient's or resident's usual living arrangement during the past month.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident} lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30925-4","display":"Person lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident} lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30926-2","display":"Person lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident} lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30927-0","display":"Person lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident} does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30928-8","display":"Person does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident} was in a medical facility."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30929-6","display":"Person was in a medical facility."}}]},{"linkId":"Section-37/GG0170J8","prefix":"GG0170J8","text":"Once the patient is standing, they will be assessed on their ability to walk at least 50 feet and make two turns. The potential ratings for performance in this task range from 'Most Dependent' to 'Independent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130EE7","prefix":"GG0130EE7","text":"The form inquires about the patient's usual performance regarding the ability to shower or bathe themselves, including tasks such as washing, rinsing, and drying themselves. It should be noted that this does not include the act of transferring in or out of the tub or shower.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185C7","prefix":"GG0185C7","text":"The form is asking about the patient's usual performance in terms of their ability to complete light daily housework. This entails maintaining a safe home environment so that the patient is not at risk from harm within their home. Examples of such housework include tasks like wiping counter tops or doing dishes.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130EE8","prefix":"GG0130EE8","text":"The form is asking about the patient's level of ability to bathe themselves, including washing, rinsing, and drying. The question does not include the process of transferring in and out of a tub or shower. The performance level designated is \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920A1","prefix":"F0920A1","text":"Does the patient require paid assistance for self-care activities such as bathing, dressing, toileting, or eating/feeding?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170E8","prefix":"GG0170E8","text":"The form asks about the patient's ability to transfer from a bed to a chair or wheelchair. It is labeled \"Most Dependent Performance\", indicating the need for assistance with this task.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125M","prefix":"GG0125M","text":"Does the patient use an assistive device such as a transfer board?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0130B8","prefix":"GG0130B8","text":"The form asks about the patient's ability to maintain oral hygiene by using suitable items to clean their teeth and, if applicable, their ability to insert and remove dentures into and from their mouth, as well as manage denture soaking and rinsing with the use of equipment. The response category for their performance is \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125S","prefix":"GG0125S","text":"The patient uses an assistive device, specifically stair rails.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0135B","prefix":"GG0135B","text":"Please ask the patient to describe at least one or two personal priorities in the area of self-care for the next six months. If the patient does not express any personal priorities in this area, please record this information below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170P7","prefix":"GG0170P7","text":"The form asks about the patient's usual performance in the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175C7","prefix":"GG0175C7","text":"Once the patient is seated in their manual wheelchair, their usual performance indicates their ability to wheel at least 150 feet in a corridor or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920E2","prefix":"F0920E2","text":"The patient has undergone medical procedures/treatments such as changing a wound dressing or a home exercise program, for which they have not paid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185K8","prefix":"GG0185K8","text":"The form asks about the patient's simple financial management skills, such as their ability to complete financial transactions, counting coins, verifying change for a single item transaction, writing a check, using online/mobile bill pay, banking, or shopping. The patient's performance is most dependent in these areas.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125C","prefix":"GG0125C","text":"Does the patient use an assistive device such as a wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185H7","prefix":"GG0185H7","text":"The patient's usual performance in medication management, specifically for oral medications, refers to their ability to prepare and take all prescribed oral medications reliably and safely. This includes administering the correct dosage at the appropriate times or intervals.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125P","prefix":"GG0125P","text":"Does the patient use an assistive device such as glasses or contact lenses?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175I7","prefix":"GG0175I7","text":"The form asks about the patient's ability to wheel for 15 minutes without stopping or resting, such as through a department store or supermarket, while seated in a wheelchair or scooter. Does the patient typically use a motorized wheelchair or scooter for this task?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125W","prefix":"GG0125W","text":"Does the patient use an assistive device such as a glucometer?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125T","prefix":"GG0125T","text":"Does the patient use an assistive device such as a lift chair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125D","prefix":"GG0125D","text":"Does the patient use an assistive device such as a limb prosthesis?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185J8","prefix":"GG0185J8","text":"The form asks about the patient's ability to manage injectable medications. It specifically addresses whether the patient can reliably and safely prepare and take all prescribed injectable medications, including the administration of the correct dosage at the correct times/intervals. The patient's performance in this area is marked as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125V","prefix":"GG0125V","text":"Does the patient use an assistive device such as a raised toilet seat?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Y","prefix":"GG0125Y","text":"Does the patient use an assistive device such as an oxygen concentrator?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175J8","prefix":"GG0175J8","text":"The question on the form is asking about the patient's ability, once seated in a wheelchair or scooter, to wheel across a street before the traffic light turns red. The answer choices are 'Motorized Wheelchair/Scooter' and 'Most Dependent Performance.'","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185I7","prefix":"GG0185I7","text":"The form asks about the patient's ability to manage their medication, specifically regarding inhalant or mist medications. It wants to know if the patient can prepare and take all prescribed inhalant or mist medications reliably and safely, including the correct dosage at the appropriate times or intervals. It asks for information about their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125U","prefix":"GG0125U","text":"Does the patient use an assistive device such as ramps?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0180A","prefix":"GG0180A","text":"Please ask the patient to describe at least one or two personal priorities in the area of mobility for the next six months. If the patient does not express any personal priorities in this area, please note this below. The answer options would be: A) Improvement in walking, B) Ability to climb stairs, C) Independence in moving, or D) No personal priorities.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0135A","prefix":"GG0135A","text":"Please ask the patient to describe at least one or two personal priorities in the area of self-care for the next six months. If the patient does not express any personal priorities in this area, please note this in their record.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0125K","prefix":"GG0125K","text":"Does the patient use an assistive device such as an electronic bed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125H","prefix":"GG0125H","text":"Does the patient use an assistive device such as a sock aid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920C2","prefix":"F0920C2","text":"The patient requires assistance with Instrumental Activities of Daily Living (IADL), such as making meals, housekeeping, telephone, shopping, or finances, which is currently unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0130A8","prefix":"GG0130A8","text":"The question on the form assesses the patient's ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them. The performance options range from independent to most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125J","prefix":"GG0125J","text":"Does the patient use an assistive device such as a bed rail?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920G1","prefix":"F0920G1","text":"Does the patient require supervision, for example due to safety concerns, and is this supervision paid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0125O","prefix":"GG0125O","text":"Does the patient use an assistive device such as a walk-in or wheel-in shower?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125B3","prefix":"GG0125B3","text":"Does the patient use an assistive device, specifically a walker with wheels?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125G","prefix":"GG0125G","text":"Does the patient use an assistive device such as a reacher or grabber?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170F7","prefix":"GG0170F7","text":"The form asks about the patient's usual performance in terms of their ability to get on and off a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125N","prefix":"GG0125N","text":"Does the patient require an assistive device such as a shower or commode chair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125X","prefix":"GG0125X","text":"Does the patient use an assistive device such as a Continuous Positive Airway Pressure (CPAP) machine?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125C1","prefix":"GG0125C1","text":"Does the patient use an assistive device such as a manual wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170G7","prefix":"GG0170G7","text":"The patient's usual performance indicates their ability to transfer in and out of a car or van on the passenger side. This does not include their ability to open/close the door or fasten the seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125B2","prefix":"GG0125B2","text":"Does the patient use an assistive device such as a walker with a seat?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185I8","prefix":"GG0185I8","text":"The form asks about the patient's ability to manage medication, specifically inhalant or mist medications. It wants to know if the patient can reliably and safely prepare and take all prescribed inhalant/mist medications, including the administration of the correct dosage at the appropriate times and intervals. The answer choices include 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130B7","prefix":"GG0130B7","text":"The form asks about the patient's oral hygiene, specifically their ability to use suitable items to clean their teeth. It also inquires about their use of dentures, if applicable, including their ability to insert and remove the dentures from their mouth, and manage denture soaking and rinsing with the use of equipment. The section is labeled \"Usual Performance.\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125I","prefix":"GG0125I","text":"Does the patient use an assistive device such as orthotics or a brace?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Z_specify","prefix":"GG0125Z_specify","text":"Does the patient use any other type of assistive device? If so, please specify.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170A8","prefix":"GG0170A8","text":"The patient's ability to roll from lying on their back to their left and right side, and return to lying on their back is most dependent on performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130CC7","prefix":"GG0130CC7","text":"The form asks about the patient's usual performance in maintaining toileting hygiene, specifically their ability to maintain perineal/menstrual hygiene and adjust clothing before and after voiding or having a bowel movement. If the patient manages an ostomy, it also includes wiping the opening but does not include managing equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920D1","prefix":"F0920D1","text":"The form asks about the patient's method of medication administration, with options that include oral, inhaled, or injectable medications. The medication administration for the patient is paid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0125E","prefix":"GG0125E","text":"Does the patient use an assistive device, such as a specialized seating pad (for example, an air-filled, gel, or shaped form pad)?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125C2","prefix":"GG0125C2","text":"Does the patient use an assistive device such as a motorized wheelchair and/or scooter?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170L8","prefix":"GG0170L8","text":"The form asks whether the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoors or outdoors. The answer choices for the patient's performance are: Most Independent Performance, Modified Independent, Supervision or Setup, Minimal Assistance, Moderate Assistance, Maximal Assistance, and Most Dependent Performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130CC8","prefix":"GG0130CC8","text":"The form asks the patient about their toileting hygiene, specifically their ability to maintain perineal/menstrual hygiene and adjust their clothes before and after voiding or having a bowel movement. If they are managing an ostomy, they should include their ability to wipe the opening, although managing the equipment is not necessary. The performance rating is either \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185A7","prefix":"GG0185A7","text":"The patient's usual performance demonstrates the ability to plan and prepare all aspects of a light, cold meal such as a bowl of cereal, sandwich, and cold drink.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920G2","prefix":"F0920G2","text":"The form asks if the patient requires supervision due to safety concerns, and specifies if this supervision is unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920C1","prefix":"F0920C1","text":"Does the patient require paid assistance for Instrumental Activities of Daily Living (IADL), such as making meals, housekeeping, using the telephone, shopping, or managing finances?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185L7","prefix":"GG0185L7","text":"The patient's usual performance in complex financial management involves the ability to complete financial decision-making tasks such as budgeting and remembering to pay bills.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185C8","prefix":"GG0185C8","text":"The form inquires about the patient's ability to perform light daily housework in order to maintain a safe home environment such that they are not at risk from harm within their own home. Examples of this housework might include tasks like wiping countertops or doing dishes. The patient's performance is labeled as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125R","prefix":"GG0125R","text":"Does the patient use an assistive device such as a communication device?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920F2","prefix":"F0920F2","text":"Does the patient manage their own equipment, such as oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies, without any payment?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185D8","prefix":"GG0185D8","text":"The form asks about the patient's ability to complete heavier periodic housework, like doing laundry, vacuuming, and cleaning the bathroom, in order to maintain a safe home environment. It also ensures the patient is not at risk for harm within their home. The category marked is 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170B8","prefix":"GG0170B8","text":"The form for the patient includes a question labeled \"Sit to lying\". This refers to the patient's ability to move from sitting on the side of the bed to lying flat on the bed. The performance is categorized as \"Most Dependent\", meaning the patient requires substantial assistance in this task.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130D7","prefix":"GG0130D7","text":"Does the patient have the ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed? Please rate their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0190A","prefix":"GG0190A","text":"Please ask the patient to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the patient does not express any personal priorities in this area, please note this below. Answer: A","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0905A","prefix":"F0905A","text":"Please ask the patient to describe at least one or two personal priorities in the area of their living arrangements for the next six months. If the patient does not express any personal priorities in this area, please note this below. The options are - A.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0920B1","prefix":"F0920B1","text":"Does the patient require mobility assistance, such as assistance with bed mobility, transfers, ambulating, or wheeling? If yes, is this assistance paid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185L8","prefix":"GG0185L8","text":"The form indicates the patient's level of ability in complex financial management, such as completing financial decision-making tasks including budgeting and remembering to pay bills. The patient's performance is recorded as mostly dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130H8","prefix":"GG0130H8","text":"The form asks about the patient's ability to put on and take off socks, shoes, or other appropriate footwear that is necessary for safe mobility, which includes dealing with fasteners, if applicable. The patient's performance in this aspect has been rated as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175H8","prefix":"GG0175H8","text":"The form is asking about the patient's ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter. The answer choices include 'Motorized Wheelchair/Scooter' and 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170A7","prefix":"GG0170A7","text":"The form asks about the patient's usual performance when it comes to their ability to roll from lying on their back to their left and right side, and then return to lying on their back.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185F7","prefix":"GG0185F7","text":"The form asks about the patient's ability to answer a telephone call in their customary manner and maintain the call for one minute or longer. It does not include getting to the phone. The question refers to the patient's usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175I8","prefix":"GG0175I8","text":"The patient questionnaire asked, \"Once the patient is seated in a wheelchair or scooter, do they have the ability to wheel without stopping or resting for 15 minutes (for example, through a department store or supermarket)?\" The answer choices include \"Motorized Wheelchair/Scooter\" and \"Most Dependent Performance.\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0190B","prefix":"GG0190B","text":"Please ask the patient to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the patient does not express any personal priorities in this area, note it below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0925A","prefix":"F0925A","text":"Please ask the patient to describe at least one or two personal priorities for their caregiving arrangement in the next six months. If the patient does not express any personal priorities in this area, please note this below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0925B","prefix":"F0925B","text":"Please ask the patient or resident to describe at least one or two personal priorities in the area of caregiving for the next six months. If the patient or resident does not express any personal priorities in this area, please note this below. The options are:\n\nA. The patient expresses personal priorities in the area of caregiving.\nB. The patient does not express any personal priorities in the area of caregiving.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170V8","prefix":"GG0170V8","text":"The form for the patient asks about his or her ability to carry something in both hands while walking indoors, such as several dishes, a light laundry basket, or a tray with food. The patient's performance in this area is identified as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]}],"_id":"pSqKSx8xyKZJ3RBfP"} {"responseType":"QuestionnaireResponse","id":"his-ha-2.00.0","questionnaire":"HIS-HA-2.00.0","title":"Hospice Item Set - Hospice Admission Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-04-27T18:38:55.449Z","item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"The form asks for the patient's Medicaid number. The patient should enter \"+\" if their Medicaid status is pending, or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-36/A0800","prefix":"A0800","text":"What is the patient's gender? The possible answers could be male, female, or prefer not to say.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record for the patient needs to be specified.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0250","prefix":"A0250","text":"The reason for the patient's assessment needs to be determined.","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"What is the patient's admission date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Where was the patient immediately preceding this admission? Was the patient admitted from another hospital, a nursing home, their residence, or another location?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0550","prefix":"A0550","text":"What is the patient's ZIP code?","type":"text","repeats":false,"readOnly":false,"maxLength":11},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"Does the patient have a National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"What is the patient's CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"The form asks for the patient's suffix.","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A1000","prefix":"A1000","text":"The patient should check all the applicable boxes for their race or ethnicity.","type":"text","repeats":true,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A1400","prefix":"A1400","text":"The patient needs to fill out the payer information and must check all the options that apply to them.","type":"text","repeats":true,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0205","prefix":"A0205","text":"What was the site of service at the patient's admission?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0245","prefix":"A0245","text":"The date when the initial nursing assessment was initiated for the patient.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the patient, resident, or responsible party asked about their preference regarding the use of cardiopulmonary resuscitation (CPR)? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"The date on which the patient or responsible party was first asked about their preference regarding the use of CPR.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the patient, or their responsible party, asked about their preferences regarding life-sustaining treatments other than CPR? Select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"What was the date when the patient or responsible party was first asked about their preferences regarding life-sustaining treatments other than CPR?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the patient or the responsible party asked about their preference regarding hospitalization? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"The date when the patient, resident, or responsible party was first asked about their preference regarding hospitalization is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the patient or their caregiver asked about any spiritual or existential concerns? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"The date on which the patient or caregiver was first asked about spiritual or existential concerns is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-9/I0010","prefix":"I0010","text":"What is the patient's principal diagnosis?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the patient or resident screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"The date of the patient's first screening for pain was:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The severity of the patient's or resident's pain was:","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"What type of standardized pain tool was used for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Is pain an active problem for the patient or resident?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment conducted on the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"When was the patient's comprehensive pain assessment conducted?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"A comprehensive pain assessment was included for the patient where they needed to check all applicable options.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the patient or resident screened for any symptoms of shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"The date of the patient's first screening for shortness of breath was:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate that the patient had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"The form asks if treatment for the patient's shortness of breath was initiated. Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"What is the date when the treatment for shortness of breath was initiated for the patient?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"What types of treatment for shortness of breath have been initiated for the patient? Please check all that apply.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"The date the patient had their opioid treatment initiated or continued is scheduled for:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid medication initiated or continued for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"The date on which the patient's PRN opioid was initiated or continued is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued for the patient? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"The date on which the patient's bowel regimen was initiated or continued is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"The patient must provide their signature and title, as well as complete section A, including the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"The patient is required to provide their signature, title, and date they completed section B.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"The patient needs to provide their signature, title, and date on the completed C section of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"The patient needs to provide their signature, title, and the date on which they completed Section D of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"The patient needs to provide their signature, title, and the sections completed, along with the date when section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"The patient must sign, provide their title, complete all sections of the form, and include the date that each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"The patient needs to provide their signature and title, fill out the necessary sections, and date the section when it's completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"The patient is required to provide their signature, title, and the date they completed Section H on the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"The patient needs to provide their signature, title, and the date they completed section I.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title, complete the sections, and include the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature and title, and complete the sections indicated on the form. The date the section was completed should also be included.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"The patient's form must include their signature and title, the sections filled out, as well as the date each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"The patient needs to provide their signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"The date on which the RN Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false}],"_id":"u3ZeiCoivos5hYeed"} {"responseType":"QuestionnaireResponse","id":"his-ha-2.00.0","questionnaire":"HIS-HA-2.00.0","title":"Hospice Item Set - Hospice Admission Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-04-27T18:38:55.449Z","item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"The form asks for the patient's Medicaid number. The patient should enter \"+\" if their Medicaid status is pending, or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-36/A0800","prefix":"A0800","text":"What is the patient's gender? The possible answers could be male, female, or prefer not to say.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record for the patient needs to be specified.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0250","prefix":"A0250","text":"The reason for the patient's assessment needs to be determined.","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"What is the patient's admission date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Where was the patient immediately preceding this admission? Was the patient admitted from another hospital, a nursing home, their residence, or another location?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0550","prefix":"A0550","text":"What is the patient's ZIP code?","type":"text","repeats":false,"readOnly":false,"maxLength":11},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"Does the patient have a National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"What is the patient's CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"The form asks for the patient's suffix.","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A1000","prefix":"A1000","text":"The patient should check all the applicable boxes for their race or ethnicity.","type":"text","repeats":true,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A1400","prefix":"A1400","text":"The patient needs to fill out the payer information and must check all the options that apply to them.","type":"text","repeats":true,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0205","prefix":"A0205","text":"What was the site of service at the patient's admission?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0245","prefix":"A0245","text":"The date when the initial nursing assessment was initiated for the patient.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the patient, resident, or responsible party asked about their preference regarding the use of cardiopulmonary resuscitation (CPR)? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"The date on which the patient or responsible party was first asked about their preference regarding the use of CPR.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the patient, or their responsible party, asked about their preferences regarding life-sustaining treatments other than CPR? Select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"What was the date when the patient or responsible party was first asked about their preferences regarding life-sustaining treatments other than CPR?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the patient or the responsible party asked about their preference regarding hospitalization? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"The date when the patient, resident, or responsible party was first asked about their preference regarding hospitalization is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the patient or their caregiver asked about any spiritual or existential concerns? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"The date on which the patient or caregiver was first asked about spiritual or existential concerns is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-9/I0010","prefix":"I0010","text":"What is the patient's principal diagnosis?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the patient or resident screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"The date of the patient's first screening for pain was:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The severity of the patient's or resident's pain was:","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"What type of standardized pain tool was used for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Is pain an active problem for the patient or resident?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment conducted on the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"When was the patient's comprehensive pain assessment conducted?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"A comprehensive pain assessment was included for the patient where they needed to check all applicable options.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the patient or resident screened for any symptoms of shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"The date of the patient's first screening for shortness of breath was:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate that the patient had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"The form asks if treatment for the patient's shortness of breath was initiated. Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"What is the date when the treatment for shortness of breath was initiated for the patient?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"What types of treatment for shortness of breath have been initiated for the patient? Please check all that apply.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"The date the patient had their opioid treatment initiated or continued is scheduled for:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid medication initiated or continued for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"The date on which the patient's PRN opioid was initiated or continued is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued for the patient? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"The date on which the patient's bowel regimen was initiated or continued is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"The patient must provide their signature and title, as well as complete section A, including the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"The patient is required to provide their signature, title, and date they completed section B.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"The patient needs to provide their signature, title, and date on the completed C section of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"The patient needs to provide their signature, title, and the date on which they completed Section D of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"The patient needs to provide their signature, title, and the sections completed, along with the date when section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"The patient must sign, provide their title, complete all sections of the form, and include the date that each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"The patient needs to provide their signature and title, fill out the necessary sections, and date the section when it's completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"The patient is required to provide their signature, title, and the date they completed Section H on the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"The patient needs to provide their signature, title, and the date they completed section I.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title, complete the sections, and include the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature and title, and complete the sections indicated on the form. The date the section was completed should also be included.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"The patient's form must include their signature and title, the sections filled out, as well as the date each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"The patient needs to provide their signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"The date on which the RN Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false}],"_id":"TEZLcTJqS66raTuRn"} {"responseType":"QuestionnaireResponse","id":"his-ha-2.00.0","questionnaire":"HIS-HA-2.00.0","title":"Hospice Item Set - Hospice Admission Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-04-27T18:38:55.449Z","item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"The form asks for the patient's Medicaid number. The patient should enter \"+\" if their Medicaid status is pending, or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-36/A0800","prefix":"A0800","text":"What is the patient's gender? The possible answers could be male, female, or prefer not to say.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record for the patient needs to be specified.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0250","prefix":"A0250","text":"The reason for the patient's assessment needs to be determined.","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"What is the patient's admission date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Where was the patient immediately preceding this admission? Was the patient admitted from another hospital, a nursing home, their residence, or another location?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0550","prefix":"A0550","text":"What is the patient's ZIP code?","type":"text","repeats":false,"readOnly":false,"maxLength":11},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"Does the patient have a National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"What is the patient's CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"The form asks for the patient's suffix.","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A1000","prefix":"A1000","text":"The patient should check all the applicable boxes for their race or ethnicity.","type":"text","repeats":true,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A1400","prefix":"A1400","text":"The patient needs to fill out the payer information and must check all the options that apply to them.","type":"text","repeats":true,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0205","prefix":"A0205","text":"What was the site of service at the patient's admission?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0245","prefix":"A0245","text":"The date when the initial nursing assessment was initiated for the patient.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the patient, resident, or responsible party asked about their preference regarding the use of cardiopulmonary resuscitation (CPR)? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"The date on which the patient or responsible party was first asked about their preference regarding the use of CPR.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the patient, or their responsible party, asked about their preferences regarding life-sustaining treatments other than CPR? Select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"What was the date when the patient or responsible party was first asked about their preferences regarding life-sustaining treatments other than CPR?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the patient or the responsible party asked about their preference regarding hospitalization? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"The date when the patient, resident, or responsible party was first asked about their preference regarding hospitalization is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the patient or their caregiver asked about any spiritual or existential concerns? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"The date on which the patient or caregiver was first asked about spiritual or existential concerns is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-9/I0010","prefix":"I0010","text":"What is the patient's principal diagnosis?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the patient or resident screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"The date of the patient's first screening for pain was:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The severity of the patient's or resident's pain was:","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"What type of standardized pain tool was used for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Is pain an active problem for the patient or resident?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment conducted on the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"When was the patient's comprehensive pain assessment conducted?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"A comprehensive pain assessment was included for the patient where they needed to check all applicable options.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the patient or resident screened for any symptoms of shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"The date of the patient's first screening for shortness of breath was:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate that the patient had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"The form asks if treatment for the patient's shortness of breath was initiated. Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"What is the date when the treatment for shortness of breath was initiated for the patient?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"What types of treatment for shortness of breath have been initiated for the patient? Please check all that apply.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"The date the patient had their opioid treatment initiated or continued is scheduled for:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid medication initiated or continued for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"The date on which the patient's PRN opioid was initiated or continued is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued for the patient? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"The date on which the patient's bowel regimen was initiated or continued is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"The patient must provide their signature and title, as well as complete section A, including the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"The patient is required to provide their signature, title, and date they completed section B.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"The patient needs to provide their signature, title, and date on the completed C section of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"The patient needs to provide their signature, title, and the date on which they completed Section D of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"The patient needs to provide their signature, title, and the sections completed, along with the date when section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"The patient must sign, provide their title, complete all sections of the form, and include the date that each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"The patient needs to provide their signature and title, fill out the necessary sections, and date the section when it's completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"The patient is required to provide their signature, title, and the date they completed Section H on the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"The patient needs to provide their signature, title, and the date they completed section I.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title, complete the sections, and include the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature and title, and complete the sections indicated on the form. The date the section was completed should also be included.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"The patient's form must include their signature and title, the sections filled out, as well as the date each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"The patient needs to provide their signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"The date on which the RN Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false}],"_id":"coqCk9aeShxyCEr5k"} {"responseType":"QuestionnaireResponse","id":"his-hd-2.00.0","questionnaire":"HIS-HD-2.00.0","title":"Hospice Item Set - Hospice Discharge Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-04-27T18:40:14.338Z","item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"The patient is required to enter a \"+\" if their Medicaid Number is pending or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-36/A0800","prefix":"A0800","text":"The patient's gender is being asked, with the answer choices being male, female, or prefer not to say.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record pertaining to the patient needs to be identified.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0250","prefix":"A0250","text":"What is the reason for the patient's assessment?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"The admission date of the patient is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0270","prefix":"A0270","text":"What is the patient's discharge date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"What is the patient's National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"What is the patient's CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"What is the patient's suffix?","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A2115","prefix":"A2115","text":"What was the patient's reason for discharge?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final three days of their life?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Did a registered nurse visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"The registered nurse visited the patient one day prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"The patient was visited by a registered nurse two days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant one day prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Did the patient visit a physician, nurse practitioner, or physician assistant two days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"The medical social worker visited the patient on the day of their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"The medical social worker visited the patient one day prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"The medical social worker visited the patient two days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Did the patient receive a visit from a chaplain or spiritual counselor on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Did the patient receive a visit from a chaplain or spiritual counselor one day prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Did the patient receive a visit from a Chaplain or Spiritual Counselor two days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Did the Licensed Professional Nurse visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Did the licensed professional nurse visit the patient one day prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Did the Licensed Professional Nurse visit the patient two days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Did an aide visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Did the aide visit the patient one day prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Did the aide visit the patient two days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final seven days of their life? This question refers to the level of care given in the final seven days.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"The patient was visited by a registered nurse three days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"The registered nurse visited the patient four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"The registered nurse visited the patient five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"The registered nurse visited the patient six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Did the patient visit a physician, nurse practitioner, or physician assistant three days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Did the patient visit a physician, nurse practitioner, or physician assistant four days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"The patient was visited by a physician, nurse practitioner, or physician assistant five days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Did the patient visit a physician, nurse practitioner, or physician assistant six days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Did the medical social worker visit the patient three days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"The medical social worker visited the patient four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"The medical social worker visited the patient five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"The medical social worker visited the patient six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Did the patient have a visit from a chaplain or spiritual counselor three days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"The patient's chaplain or spiritual counselor visited four days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"The patient was visited by a Chaplain or Spiritual Counselor five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Did the patient receive a visit from a chaplain or spiritual counselor six days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"The patient was visited by a Licensed Professional Nurse three days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"The patient was visited by a Licensed Professional Nurse four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Did the licensed professional nurse visit the patient five days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"The patient was visited by a Licensed Professional Nurse six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Did the aide visit the patient three days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"The patient received visits from the aide four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Did the aide visit the patient five days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Did the aide visit the patient six days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"The patient is required to provide their signature and title, and to acknowledge the sections and date that the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"The patient is required to provide their signature, title, and the date on which they completed Section B.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"The patient is asked to provide their signature and title in the designated sections, and to also indicate the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"The form for the patient asks for the patient's signature, their title, the sections they have completed, and the date they completed section D.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"The section indicated as \"Signature, Title, Sections, Date Section Completed E\" on the patient's form needs to be filled out.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"The patient's signature, title, and the date of completion are required in section F.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"The patient is required to provide their signature and title in the designated sections and indicate the date when they completed Section G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"The patient's form includes sections for signature, title, and date of completion, all of which must be filled out by Section H.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"The patient must provide their signature, title, date, and completed sections in section I.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title, and complete sections J of the form. This needs to be done by a specific date.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"The sections, signature, title, and the date when the section was completed are required information for patient K's form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"The sections of the form, including the signature, title, and date section, were completed by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"The form requires the patient's signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"The date on which the RN Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false}],"_id":"XDEpEXteFmyumNR3D"} {"responseType":"QuestionnaireResponse","id":"his-hd-2.00.0","questionnaire":"HIS-HD-2.00.0","title":"Hospice Item Set - Hospice Discharge Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-04-27T18:40:14.338Z","item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"The patient is required to enter a \"+\" if their Medicaid Number is pending or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-36/A0800","prefix":"A0800","text":"The patient's gender is being asked, with the answer choices being male, female, or prefer not to say.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record pertaining to the patient needs to be identified.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0250","prefix":"A0250","text":"What is the reason for the patient's assessment?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"The admission date of the patient is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0270","prefix":"A0270","text":"What is the patient's discharge date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"What is the patient's National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"What is the patient's CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"What is the patient's suffix?","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A2115","prefix":"A2115","text":"What was the patient's reason for discharge?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final three days of their life?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Did a registered nurse visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"The registered nurse visited the patient one day prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"The patient was visited by a registered nurse two days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant one day prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Did the patient visit a physician, nurse practitioner, or physician assistant two days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"The medical social worker visited the patient on the day of their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"The medical social worker visited the patient one day prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"The medical social worker visited the patient two days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Did the patient receive a visit from a chaplain or spiritual counselor on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Did the patient receive a visit from a chaplain or spiritual counselor one day prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Did the patient receive a visit from a Chaplain or Spiritual Counselor two days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Did the Licensed Professional Nurse visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Did the licensed professional nurse visit the patient one day prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Did the Licensed Professional Nurse visit the patient two days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Did an aide visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Did the aide visit the patient one day prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Did the aide visit the patient two days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final seven days of their life? This question refers to the level of care given in the final seven days.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"The patient was visited by a registered nurse three days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"The registered nurse visited the patient four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"The registered nurse visited the patient five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"The registered nurse visited the patient six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Did the patient visit a physician, nurse practitioner, or physician assistant three days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Did the patient visit a physician, nurse practitioner, or physician assistant four days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"The patient was visited by a physician, nurse practitioner, or physician assistant five days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Did the patient visit a physician, nurse practitioner, or physician assistant six days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Did the medical social worker visit the patient three days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"The medical social worker visited the patient four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"The medical social worker visited the patient five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"The medical social worker visited the patient six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Did the patient have a visit from a chaplain or spiritual counselor three days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"The patient's chaplain or spiritual counselor visited four days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"The patient was visited by a Chaplain or Spiritual Counselor five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Did the patient receive a visit from a chaplain or spiritual counselor six days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"The patient was visited by a Licensed Professional Nurse three days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"The patient was visited by a Licensed Professional Nurse four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Did the licensed professional nurse visit the patient five days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"The patient was visited by a Licensed Professional Nurse six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Did the aide visit the patient three days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"The patient received visits from the aide four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Did the aide visit the patient five days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Did the aide visit the patient six days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"The patient is required to provide their signature and title, and to acknowledge the sections and date that the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"The patient is required to provide their signature, title, and the date on which they completed Section B.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"The patient is asked to provide their signature and title in the designated sections, and to also indicate the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"The form for the patient asks for the patient's signature, their title, the sections they have completed, and the date they completed section D.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"The section indicated as \"Signature, Title, Sections, Date Section Completed E\" on the patient's form needs to be filled out.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"The patient's signature, title, and the date of completion are required in section F.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"The patient is required to provide their signature and title in the designated sections and indicate the date when they completed Section G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"The patient's form includes sections for signature, title, and date of completion, all of which must be filled out by Section H.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"The patient must provide their signature, title, date, and completed sections in section I.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title, and complete sections J of the form. This needs to be done by a specific date.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"The sections, signature, title, and the date when the section was completed are required information for patient K's form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"The sections of the form, including the signature, title, and date section, were completed by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"The form requires the patient's signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"The date on which the RN Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false}],"_id":"wxBMSjGqToT2Ktx6Y"} {"responseType":"QuestionnaireResponse","id":"his-hd-2.00.0","questionnaire":"HIS-HD-2.00.0","title":"Hospice Item Set - Hospice Discharge Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-04-27T18:40:14.338Z","item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"The patient is required to enter a \"+\" if their Medicaid Number is pending or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-36/A0800","prefix":"A0800","text":"The patient's gender is being asked, with the answer choices being male, female, or prefer not to say.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record pertaining to the patient needs to be identified.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0250","prefix":"A0250","text":"What is the reason for the patient's assessment?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"The admission date of the patient is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0270","prefix":"A0270","text":"What is the patient's discharge date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"What is the patient's National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"What is the patient's CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"What is the patient's suffix?","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A2115","prefix":"A2115","text":"What was the patient's reason for discharge?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final three days of their life?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Did a registered nurse visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"The registered nurse visited the patient one day prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"The patient was visited by a registered nurse two days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant one day prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Did the patient visit a physician, nurse practitioner, or physician assistant two days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"The medical social worker visited the patient on the day of their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"The medical social worker visited the patient one day prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"The medical social worker visited the patient two days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Did the patient receive a visit from a chaplain or spiritual counselor on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Did the patient receive a visit from a chaplain or spiritual counselor one day prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Did the patient receive a visit from a Chaplain or Spiritual Counselor two days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Did the Licensed Professional Nurse visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Did the licensed professional nurse visit the patient one day prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Did the Licensed Professional Nurse visit the patient two days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Did an aide visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Did the aide visit the patient one day prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Did the aide visit the patient two days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final seven days of their life? This question refers to the level of care given in the final seven days.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"The patient was visited by a registered nurse three days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"The registered nurse visited the patient four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"The registered nurse visited the patient five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"The registered nurse visited the patient six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Did the patient visit a physician, nurse practitioner, or physician assistant three days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Did the patient visit a physician, nurse practitioner, or physician assistant four days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"The patient was visited by a physician, nurse practitioner, or physician assistant five days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Did the patient visit a physician, nurse practitioner, or physician assistant six days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Did the medical social worker visit the patient three days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"The medical social worker visited the patient four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"The medical social worker visited the patient five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"The medical social worker visited the patient six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Did the patient have a visit from a chaplain or spiritual counselor three days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"The patient's chaplain or spiritual counselor visited four days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"The patient was visited by a Chaplain or Spiritual Counselor five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Did the patient receive a visit from a chaplain or spiritual counselor six days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"The patient was visited by a Licensed Professional Nurse three days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"The patient was visited by a Licensed Professional Nurse four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Did the licensed professional nurse visit the patient five days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"The patient was visited by a Licensed Professional Nurse six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Did the aide visit the patient three days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"The patient received visits from the aide four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Did the aide visit the patient five days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Did the aide visit the patient six days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"The patient is required to provide their signature and title, and to acknowledge the sections and date that the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"The patient is required to provide their signature, title, and the date on which they completed Section B.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"The patient is asked to provide their signature and title in the designated sections, and to also indicate the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"The form for the patient asks for the patient's signature, their title, the sections they have completed, and the date they completed section D.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"The section indicated as \"Signature, Title, Sections, Date Section Completed E\" on the patient's form needs to be filled out.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"The patient's signature, title, and the date of completion are required in section F.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"The patient is required to provide their signature and title in the designated sections and indicate the date when they completed Section G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"The patient's form includes sections for signature, title, and date of completion, all of which must be filled out by Section H.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"The patient must provide their signature, title, date, and completed sections in section I.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title, and complete sections J of the form. This needs to be done by a specific date.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"The sections, signature, title, and the date when the section was completed are required information for patient K's form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"The sections of the form, including the signature, title, and date section, were completed by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"The form requires the patient's signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"The date on which the RN Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false}],"_id":"LorPFGt8npQPL8QHA"} {"responseType":"QuestionnaireResponse","id":"irf-pai-ia-3.0","questionnaire":"IRF-PAI-IA-3.0","title":"Inpatient Rehabilitation Facility Patient Assessment Instrument - IRF Admission","description":"Assessment data collected on all Medicare Part A fee-for-service patients who receive services under Part A from an inpatient rehabilitation facility (IRF) at admission and upon discharge.","status":"draft","authored":"2024-04-27T18:34:15.837Z","item":[{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0700","prefix":"A0700","text":"The patient should enter a \"+\" in the Medicaid Number field if the application is pending, or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-38/A0800","prefix":"A0800","text":"The patient's gender is required. Is the patient male or female?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Male"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Female"}}]},{"linkId":"Section-38/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/A1200","prefix":"A1200","text":"What is the patient's marital status? Is he/she single, married, divorced, separated, or widowed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Never married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Widowed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Separated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Divorced"}}]},{"linkId":"Section-38/A0220","prefix":"A0220","text":"What is the admission date for the patient?","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/11","prefix":"11","text":"What is the zip code of the patient's or resident's pre-hospital residence?","type":"text","repeats":false,"readOnly":false,"maxLength":5},{"linkId":"Section-38/13","prefix":"13","text":"The assessment reference date for the patient has been set.","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/14","prefix":"14","text":"The admission class of the patient is categorized under which category?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Initial Rehab"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Evaluation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Readmission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unplanned Discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Continuing Rehabilitation"}}]},{"linkId":"Section-38/17","prefix":"17","text":"Does the patient live at home prior to hospitalization? If the pre-hospital living setting is the patient's home, please code accordingly.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Alone"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Family / Relatives"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Friends"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Attendant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Other"}}]},{"linkId":"Section-38/15A","prefix":"15A","text":"From where was the patient admitted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}}]},{"linkId":"Section-38/16A","prefix":"16A","text":"The patient's pre-hospital living setting is required. Please use codes from the 'Admit From' category.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}}]},{"linkId":"Section-38/1A","prefix":"1A","text":"What is the name of the facility or provider for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":50},{"linkId":"Section-38/5B","prefix":"5B","text":"What is the patient's or resident's identification number?","type":"text","repeats":false,"readOnly":false,"maxLength":50},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Please check all the boxes that apply to the patient's race and ethnicity.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}]},{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Please record the most recent height measurement in inches for the patient since their admission.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"The patient's weight in pounds should be based on the most recent measure taken within the specified time period. The weight measurement must be executed consistently, adhering to the standard practice of the facility or setting, such as in the morning after voiding, before meals, with shoes off, etc.","type":"integer","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-41/21A","prefix":"21A","text":"The impairment group upon admission refers to the condition that required the patient to be admitted to rehabilitation; this should be coded according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-41/23","prefix":"23","text":"When did the impairment of the patient first begin?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Does the patient have any arthritis conditions recorded in either the impairment group, etiologic diagnosis, or comorbid conditions that meet all the regulatory requirements for Inpatient Rehabilitation Facility (IRF) classification?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-41/22A","prefix":"22A","text":"The form asks for the patient's etiologic diagnosis A.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/22B","prefix":"22B","text":"The form asks the patient for their etiologic diagnosis B.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/22C","prefix":"22C","text":"The form for the patient includes a section on etiologic diagnosis C.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24A","prefix":"24A","text":"Does the patient have Comorbid Condition A?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24B","prefix":"24B","text":"Does the patient have Comorbid Condition B?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24C","prefix":"24C","text":"Does the patient have Comorbid Condition C?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24D","prefix":"24D","text":"Does the patient have a comorbid condition D?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24E","prefix":"24E","text":"Does the patient have a comorbid condition E?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24F","prefix":"24F","text":"Does the patient have a comorbid condition F?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24G","prefix":"24G","text":"Does the patient have a comorbid condition G?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24H","prefix":"24H","text":"Does the patient have a comorbid condition H? Please select 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24I","prefix":"24I","text":"Does the patient have a comorbid condition? Please select either 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24J","prefix":"24J","text":"Does the patient have comorbid condition J?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24K","prefix":"24K","text":"Does the patient have a comorbid condition K?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24L","prefix":"24L","text":"Does the patient have any comorbid conditions? Please list them.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24M","prefix":"24M","text":"The patient has a comorbid condition labelled as M.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24N","prefix":"24N","text":"Does the patient have any comorbid conditions? Please select 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24O","prefix":"24O","text":"Does the patient have any comorbid conditions?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24P","prefix":"24P","text":"Does the patient have a comorbid condition P?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Does the patient have a comorbid condition?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24R","prefix":"24R","text":"Does the patient have a comorbid condition R?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24S","prefix":"24S","text":"The form inquires about the patient's comorbid conditions.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24T","prefix":"24T","text":"Does the patient have a comorbid condition? Please choose one: Yes or No.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24U","prefix":"24U","text":"The patient has a comorbid condition, referred to as Condition U.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24V","prefix":"24V","text":"Does the patient have a comorbid condition V?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24W","prefix":"24W","text":"Does the patient have a comorbid condition W?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24X","prefix":"24X","text":"Does the patient have a comorbid condition X?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Does the patient have a comorbid condition labeled as Y?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-40/20A","prefix":"20A","text":"The primary source of information about the patient is the patient themselves.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}]},{"linkId":"Section-40/20B","prefix":"20B","text":"The form asks the patient to provide a secondary source of information.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}]},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"The patient's ability to express ideas and wants, considering both verbal and non-verbal expression and excluding language barriers, is being evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}]},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Does the patient understand verbal and non-verbal content with the use of a hearing aid or device, excluding language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}]},{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should a brief interview for mental status be conducted? An attempt should be made to conduct an interview with all patients or residents.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-3/C0200","prefix":"C0200","text":"The form asks the patient: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" The form then records the number of words the patient repeated after the first attempt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}]},{"linkId":"Section-3/C0500","prefix":"C0500","text":"The BIMS Summary Score requires the addition of scores for the Brief Interview for Mental Status questions, with the total score filled in, ranging from 00-15. If the patient or resident was unable to complete the interview, enter 99.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the staff conduct an assessment for the patient's mental status?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}]},{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"The form asks the patient, \"Please tell me what year it is right now,\" to determine if they are able to accurately report the current year.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}]},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"The form asks the patient: \"What month are we in right now?\" The patient is expected to be able to report the correct month.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}]},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"The form asks the patient, \"What day of the week is today?\" The patient is then expected to be able to report the correct day of the week.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}]},{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"The patient is able to recall the word \"sock\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"The patient is able to recall the color \"blue\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Is the patient able to recall the word \"bed\"?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0900","prefix":"C0900","text":"The form asked to check all the items that the patient or resident was normally able to recall, indicating their memory or recall ability.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}]},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"The question on the form asks about the patient's ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them. This refers to their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"The patient's oral hygiene refers to their ability to use suitable items to clean their teeth. If applicable, their ability to handle dentures is evaluated by their capability to insert and remove them into and from the mouth, as well as successfully managing the soaking and rinsing of the dentures with the use of equipment. This is part of their admission performance assessment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"Does the patient have the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement? If the patient is managing an ostomy, does this include wiping the opening but not managing the equipment? Please assess their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"The discharge goal for the patient or resident is to gain the ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"The patient's oral hygiene pertains to their ability to use suitable items to clean their teeth. If applicable, their denture care involves the ability to insert and remove dentures into and from the mouth, as well as managing denture soaking and rinsing with the use of equipment. The discharge goal is to ensure these abilities.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"The discharge goal is for the patient to have the ability to maintain perineal hygiene, adjust their clothes before and after voiding or having a bowel movement. If they are managing an ostomy, this includes wiping the opening but not managing the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"The form asks about the patient's ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed during their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"The form asks about the patient's ability to move from sitting on the side of the bed to lying flat on the bed at the time of admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"The form asks about the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. This is referred to as 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"The discharge goal for the patient is to have the ability to roll from lying on their back to their left and right side, and then return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"The discharge goal for the patient includes the ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"The patient's discharge goal is the ability to move from lying on the back to sitting on the side of the bed without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"Does the patient have the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"The patient's admission performance includes the ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"The admission form poses a question regarding the patient's ability to transfer to and from a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"The question on the form asks about the patient's admission performance, specifically their ability to walk at least 10 feet in a room, corridor, or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"The form asks about the patient's admission performance, specifically their ability to walk at least 50 feet and make two turns once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"The form asks about the patient's admission performance, specifically, once standing, does the patient have the ability to walk at least 150 feet in a corridor or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"Once the patient is seated in the wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. This is a requirement for admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"The form asks about the patient's admission performance regarding their ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K3","prefix":"GG0170K3","text":"Does the patient have the ability, once standing, to walk at least 150 feet in a corridor or similar space? This will be evaluated as part of their discharge performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"The discharge goal for the patient is to develop the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"The discharge goal for the patient is to be able to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"The discharge goal for the patient is to have the ability to get on and off a toilet or commode independently.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"The discharge goal for the patient is to achieve the ability to walk at least 10 feet once standing, whether it's in a room, corridor, or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"The form asks if, once standing, the patient has the ability to walk at least 50 feet and make two turns. The answer options for this question are \"Yes\" or \"No\". This information will help set a discharge goal for the patient.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"The form inquires if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The goal is to attain this ability by the time of discharge.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"The discharge goal for the patient is to be able once seated in the wheelchair or scooter, to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"The discharge goal for the patient is to have the ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the patient or resident use a wheelchair and/or scooter upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Please indicate the type of wheelchair or scooter that the patient uses upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"The patient is required to indicate the type of wheelchair or scooter used upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"The form inquires about the patient's ability to bathe themselves, which includes washing, rinsing, and drying themselves, excluding washing of the back and hair. It does not consider the ability to transfer in or out of the tub or shower. This information is required for the Admission Performance assessment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"The admission performance form inquires about the patient's ability to dress and undress above the waist, including the handling of fasteners if applicable, under the section labeled 'Upper Body Dressing'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"On the admission form, it asks about the patient's ability to dress and undress below the waist, including handling fasteners. It does not include dealing with footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"The form asks about the patient's ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable. This is in reference to their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"The form asks about the patient's ability to transfer in and out of a car or van from the passenger side upon admission. This does not include the patient's ability to open or close the door or fasten their seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"The form asks about the patient's ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel, in terms of their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"The form asks about the patient's ability to go up and down a curb and/or up and down one step, as a measure of their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170N1","prefix":"GG0170N1","text":"The patient's admission performance indicates their ability to go up and down four steps, either with or without the aid of a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170O1","prefix":"GG0170O1","text":"The question on the form asks about the patient's ability to go up and down 12 steps with or without a rail. The label is \"Admission Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170P1","prefix":"GG0170P1","text":"The form asks about the patient's ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor. This question is referred to as the 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130E2","prefix":"GG0130E2","text":"The form asks about the patient's ability to shower or bathe themselves, which includes washing, rinsing, and drying, but excludes washing of the back and hair. It is important to note, this does not include the patient's ability to transfer in and out of the tub or shower. The focus of this question is to understand the patient's discharge goal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130F2","prefix":"GG0130F2","text":"The patient's discharge goal includes developing the ability to dress and undress themselves above the waist, including managing fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130G2","prefix":"GG0130G2","text":"The discharge goal for the patient is to develop the ability to dress and undress below the waist, including handling fasteners, but this does not include managing footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130H2","prefix":"GG0130H2","text":"The discharge goal for the patient is to develop the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including managing fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"The patient's discharge goal is to be able to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten the seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"The patient's discharge goal is to have the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoors or outdoors.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"The discharge goal for the patient is the ability to go up and down a curb and/or up and down one step.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"The discharge goal for the patient is to develop the ability to go up and down four steps, with or without the assistance of a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"The discharge goal for the patient is to have the ability to go up and down 12 steps with or without a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"The discharge goal for the patient is to develop the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Please code the patient's or resident's need for assistance with activities such as bathing, dressing, using the toilet, and eating prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"The form asks for the patient's or resident's level of need for assistance with indoor mobility, specifically walking from room to room, prior to the current illness, exacerbation, or injury. This includes whether they required a device such as a cane, crutch, or walker.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Please code the patient's or resident's need for assistance with internal or external stairs, whether with or without a device such as a cane, crutch, or walker, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Please code the patient's need for assistance with planning regular tasks, such as shopping or remembering to take medication, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"The form asks for information about the devices and aids that the patient or resident was using prior to their current illness, exacerbation, or injury. It requests that all applicable options be checked.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Please select the category that best describes the bowel continence of the patient or resident.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}]},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Please select the one category that best describes the patient's bladder continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}]},{"linkId":"Section-9/I0000","prefix":"I0000","text":"The form asks the patient to check all active diagnoses they have had in the last 7 days. It should be noted that the diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-10/J1750","prefix":"J1750","text":"Does the patient or resident have a history of falls, specifically, have they experienced two or more falls in the past year or any fall that resulted in injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}]},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Did the patient have any major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}]},{"linkId":"Section-11/K0110","prefix":"K0110","text":"Indicate the patient's usual ability to swallow by checking all applicable boxes pertaining to their swallowing and nutritional status.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}]},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Does the patient or resident have one or more unhealed pressure ulcers or injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"The form is asking the patient to report the number of Stage 2 pressure ulcers they currently have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"The patient has been asked to indicate the number of Stage 3 pressure ulcers they have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"The patient has a certain number of stage 4 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"How many unstageable pressure ulcers or injuries does the patient have due to a non-removable dressing or device?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"The form is asking the patient about the number of unstageable pressure ulcers they have due to the coverage of the wound bed by slough and/or eschar.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"The patient has a number of unstageable pressure injuries presenting as deep tissue injury.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"The form is asking the patient to disclose the number of Stage 1 pressure injuries they have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Did a complete drug regimen review conducted for the patient identify any potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}]},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Did the facility or setting contact a physician or a designated representative by midnight of the next calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues for the patient?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-15/O0100","prefix":"O0100","text":"The patient should check all of the following special treatments, procedures, and programs that were performed on them.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}]},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"The form for the patient includes sections such as the signature, title, and date section A that need to be completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"The patient must provide their signature, title, and date in the sections where the section completion is indicated by a 'B'.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"The sections labeled \"Signature\", \"Title\", \"Sections\", and \"Date Section Completed C\" must be filled out by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"The sections of the form completed by the patient are signed and dated, with their title also mentioned.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"The patient should fill out the signature, title, and sections, then indicate the date the section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"The patient's signature, title, and the date the form sections were completed are required in section F.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"The patient needs to provide their Signature, Title, and complete the Sections mentioned in the form, including the Date Section Completed G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"The patient needs to include their signature, title, and date on the completed sections H of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"The patient needs to provide their signature and title, complete the sections, and indicate the date on which the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"The patient is required to provide their signature, title, and the date on which the sections were completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature, their title, and fill out the sections on the form, indicating the date each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"The patient's form includes a signature, title, sections, and a section indicating the date the form was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100}],"_id":"8HPhvRhqjmSfDm7L2"} {"responseType":"QuestionnaireResponse","id":"irf-pai-ia-3.0","questionnaire":"IRF-PAI-IA-3.0","title":"Inpatient Rehabilitation Facility Patient Assessment Instrument - IRF Admission","description":"Assessment data collected on all Medicare Part A fee-for-service patients who receive services under Part A from an inpatient rehabilitation facility (IRF) at admission and upon discharge.","status":"draft","authored":"2024-04-27T18:34:15.837Z","item":[{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0700","prefix":"A0700","text":"The patient should enter a \"+\" in the Medicaid Number field if the application is pending, or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-38/A0800","prefix":"A0800","text":"The patient's gender is required. Is the patient male or female?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Male"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Female"}}]},{"linkId":"Section-38/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/A1200","prefix":"A1200","text":"What is the patient's marital status? Is he/she single, married, divorced, separated, or widowed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Never married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Widowed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Separated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Divorced"}}]},{"linkId":"Section-38/A0220","prefix":"A0220","text":"What is the admission date for the patient?","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/11","prefix":"11","text":"What is the zip code of the patient's or resident's pre-hospital residence?","type":"text","repeats":false,"readOnly":false,"maxLength":5},{"linkId":"Section-38/13","prefix":"13","text":"The assessment reference date for the patient has been set.","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/14","prefix":"14","text":"The admission class of the patient is categorized under which category?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Initial Rehab"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Evaluation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Readmission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unplanned Discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Continuing Rehabilitation"}}]},{"linkId":"Section-38/17","prefix":"17","text":"Does the patient live at home prior to hospitalization? If the pre-hospital living setting is the patient's home, please code accordingly.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Alone"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Family / Relatives"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Friends"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Attendant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Other"}}]},{"linkId":"Section-38/15A","prefix":"15A","text":"From where was the patient admitted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}}]},{"linkId":"Section-38/16A","prefix":"16A","text":"The patient's pre-hospital living setting is required. Please use codes from the 'Admit From' category.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}}]},{"linkId":"Section-38/1A","prefix":"1A","text":"What is the name of the facility or provider for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":50},{"linkId":"Section-38/5B","prefix":"5B","text":"What is the patient's or resident's identification number?","type":"text","repeats":false,"readOnly":false,"maxLength":50},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Please check all the boxes that apply to the patient's race and ethnicity.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}]},{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Please record the most recent height measurement in inches for the patient since their admission.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"The patient's weight in pounds should be based on the most recent measure taken within the specified time period. The weight measurement must be executed consistently, adhering to the standard practice of the facility or setting, such as in the morning after voiding, before meals, with shoes off, etc.","type":"integer","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-41/21A","prefix":"21A","text":"The impairment group upon admission refers to the condition that required the patient to be admitted to rehabilitation; this should be coded according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-41/23","prefix":"23","text":"When did the impairment of the patient first begin?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Does the patient have any arthritis conditions recorded in either the impairment group, etiologic diagnosis, or comorbid conditions that meet all the regulatory requirements for Inpatient Rehabilitation Facility (IRF) classification?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-41/22A","prefix":"22A","text":"The form asks for the patient's etiologic diagnosis A.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/22B","prefix":"22B","text":"The form asks the patient for their etiologic diagnosis B.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/22C","prefix":"22C","text":"The form for the patient includes a section on etiologic diagnosis C.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24A","prefix":"24A","text":"Does the patient have Comorbid Condition A?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24B","prefix":"24B","text":"Does the patient have Comorbid Condition B?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24C","prefix":"24C","text":"Does the patient have Comorbid Condition C?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24D","prefix":"24D","text":"Does the patient have a comorbid condition D?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24E","prefix":"24E","text":"Does the patient have a comorbid condition E?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24F","prefix":"24F","text":"Does the patient have a comorbid condition F?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24G","prefix":"24G","text":"Does the patient have a comorbid condition G?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24H","prefix":"24H","text":"Does the patient have a comorbid condition H? Please select 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24I","prefix":"24I","text":"Does the patient have a comorbid condition? Please select either 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24J","prefix":"24J","text":"Does the patient have comorbid condition J?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24K","prefix":"24K","text":"Does the patient have a comorbid condition K?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24L","prefix":"24L","text":"Does the patient have any comorbid conditions? Please list them.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24M","prefix":"24M","text":"The patient has a comorbid condition labelled as M.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24N","prefix":"24N","text":"Does the patient have any comorbid conditions? Please select 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24O","prefix":"24O","text":"Does the patient have any comorbid conditions?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24P","prefix":"24P","text":"Does the patient have a comorbid condition P?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Does the patient have a comorbid condition?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24R","prefix":"24R","text":"Does the patient have a comorbid condition R?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24S","prefix":"24S","text":"The form inquires about the patient's comorbid conditions.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24T","prefix":"24T","text":"Does the patient have a comorbid condition? Please choose one: Yes or No.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24U","prefix":"24U","text":"The patient has a comorbid condition, referred to as Condition U.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24V","prefix":"24V","text":"Does the patient have a comorbid condition V?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24W","prefix":"24W","text":"Does the patient have a comorbid condition W?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24X","prefix":"24X","text":"Does the patient have a comorbid condition X?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Does the patient have a comorbid condition labeled as Y?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-40/20A","prefix":"20A","text":"The primary source of information about the patient is the patient themselves.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}]},{"linkId":"Section-40/20B","prefix":"20B","text":"The form asks the patient to provide a secondary source of information.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}]},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"The patient's ability to express ideas and wants, considering both verbal and non-verbal expression and excluding language barriers, is being evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}]},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Does the patient understand verbal and non-verbal content with the use of a hearing aid or device, excluding language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}]},{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should a brief interview for mental status be conducted? An attempt should be made to conduct an interview with all patients or residents.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-3/C0200","prefix":"C0200","text":"The form asks the patient: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" The form then records the number of words the patient repeated after the first attempt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}]},{"linkId":"Section-3/C0500","prefix":"C0500","text":"The BIMS Summary Score requires the addition of scores for the Brief Interview for Mental Status questions, with the total score filled in, ranging from 00-15. If the patient or resident was unable to complete the interview, enter 99.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the staff conduct an assessment for the patient's mental status?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}]},{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"The form asks the patient, \"Please tell me what year it is right now,\" to determine if they are able to accurately report the current year.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}]},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"The form asks the patient: \"What month are we in right now?\" The patient is expected to be able to report the correct month.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}]},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"The form asks the patient, \"What day of the week is today?\" The patient is then expected to be able to report the correct day of the week.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}]},{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"The patient is able to recall the word \"sock\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"The patient is able to recall the color \"blue\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Is the patient able to recall the word \"bed\"?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0900","prefix":"C0900","text":"The form asked to check all the items that the patient or resident was normally able to recall, indicating their memory or recall ability.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}]},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"The question on the form asks about the patient's ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them. This refers to their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"The patient's oral hygiene refers to their ability to use suitable items to clean their teeth. If applicable, their ability to handle dentures is evaluated by their capability to insert and remove them into and from the mouth, as well as successfully managing the soaking and rinsing of the dentures with the use of equipment. This is part of their admission performance assessment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"Does the patient have the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement? If the patient is managing an ostomy, does this include wiping the opening but not managing the equipment? Please assess their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"The discharge goal for the patient or resident is to gain the ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"The patient's oral hygiene pertains to their ability to use suitable items to clean their teeth. If applicable, their denture care involves the ability to insert and remove dentures into and from the mouth, as well as managing denture soaking and rinsing with the use of equipment. The discharge goal is to ensure these abilities.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"The discharge goal is for the patient to have the ability to maintain perineal hygiene, adjust their clothes before and after voiding or having a bowel movement. If they are managing an ostomy, this includes wiping the opening but not managing the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"The form asks about the patient's ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed during their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"The form asks about the patient's ability to move from sitting on the side of the bed to lying flat on the bed at the time of admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"The form asks about the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. This is referred to as 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"The discharge goal for the patient is to have the ability to roll from lying on their back to their left and right side, and then return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"The discharge goal for the patient includes the ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"The patient's discharge goal is the ability to move from lying on the back to sitting on the side of the bed without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"Does the patient have the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"The patient's admission performance includes the ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"The admission form poses a question regarding the patient's ability to transfer to and from a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"The question on the form asks about the patient's admission performance, specifically their ability to walk at least 10 feet in a room, corridor, or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"The form asks about the patient's admission performance, specifically their ability to walk at least 50 feet and make two turns once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"The form asks about the patient's admission performance, specifically, once standing, does the patient have the ability to walk at least 150 feet in a corridor or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"Once the patient is seated in the wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. This is a requirement for admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"The form asks about the patient's admission performance regarding their ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K3","prefix":"GG0170K3","text":"Does the patient have the ability, once standing, to walk at least 150 feet in a corridor or similar space? This will be evaluated as part of their discharge performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"The discharge goal for the patient is to develop the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"The discharge goal for the patient is to be able to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"The discharge goal for the patient is to have the ability to get on and off a toilet or commode independently.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"The discharge goal for the patient is to achieve the ability to walk at least 10 feet once standing, whether it's in a room, corridor, or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"The form asks if, once standing, the patient has the ability to walk at least 50 feet and make two turns. The answer options for this question are \"Yes\" or \"No\". This information will help set a discharge goal for the patient.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"The form inquires if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The goal is to attain this ability by the time of discharge.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"The discharge goal for the patient is to be able once seated in the wheelchair or scooter, to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"The discharge goal for the patient is to have the ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the patient or resident use a wheelchair and/or scooter upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Please indicate the type of wheelchair or scooter that the patient uses upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"The patient is required to indicate the type of wheelchair or scooter used upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"The form inquires about the patient's ability to bathe themselves, which includes washing, rinsing, and drying themselves, excluding washing of the back and hair. It does not consider the ability to transfer in or out of the tub or shower. This information is required for the Admission Performance assessment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"The admission performance form inquires about the patient's ability to dress and undress above the waist, including the handling of fasteners if applicable, under the section labeled 'Upper Body Dressing'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"On the admission form, it asks about the patient's ability to dress and undress below the waist, including handling fasteners. It does not include dealing with footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"The form asks about the patient's ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable. This is in reference to their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"The form asks about the patient's ability to transfer in and out of a car or van from the passenger side upon admission. This does not include the patient's ability to open or close the door or fasten their seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"The form asks about the patient's ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel, in terms of their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"The form asks about the patient's ability to go up and down a curb and/or up and down one step, as a measure of their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170N1","prefix":"GG0170N1","text":"The patient's admission performance indicates their ability to go up and down four steps, either with or without the aid of a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170O1","prefix":"GG0170O1","text":"The question on the form asks about the patient's ability to go up and down 12 steps with or without a rail. The label is \"Admission Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170P1","prefix":"GG0170P1","text":"The form asks about the patient's ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor. This question is referred to as the 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130E2","prefix":"GG0130E2","text":"The form asks about the patient's ability to shower or bathe themselves, which includes washing, rinsing, and drying, but excludes washing of the back and hair. It is important to note, this does not include the patient's ability to transfer in and out of the tub or shower. The focus of this question is to understand the patient's discharge goal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130F2","prefix":"GG0130F2","text":"The patient's discharge goal includes developing the ability to dress and undress themselves above the waist, including managing fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130G2","prefix":"GG0130G2","text":"The discharge goal for the patient is to develop the ability to dress and undress below the waist, including handling fasteners, but this does not include managing footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130H2","prefix":"GG0130H2","text":"The discharge goal for the patient is to develop the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including managing fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"The patient's discharge goal is to be able to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten the seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"The patient's discharge goal is to have the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoors or outdoors.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"The discharge goal for the patient is the ability to go up and down a curb and/or up and down one step.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"The discharge goal for the patient is to develop the ability to go up and down four steps, with or without the assistance of a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"The discharge goal for the patient is to have the ability to go up and down 12 steps with or without a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"The discharge goal for the patient is to develop the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Please code the patient's or resident's need for assistance with activities such as bathing, dressing, using the toilet, and eating prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"The form asks for the patient's or resident's level of need for assistance with indoor mobility, specifically walking from room to room, prior to the current illness, exacerbation, or injury. This includes whether they required a device such as a cane, crutch, or walker.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Please code the patient's or resident's need for assistance with internal or external stairs, whether with or without a device such as a cane, crutch, or walker, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Please code the patient's need for assistance with planning regular tasks, such as shopping or remembering to take medication, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"The form asks for information about the devices and aids that the patient or resident was using prior to their current illness, exacerbation, or injury. It requests that all applicable options be checked.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Please select the category that best describes the bowel continence of the patient or resident.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}]},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Please select the one category that best describes the patient's bladder continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}]},{"linkId":"Section-9/I0000","prefix":"I0000","text":"The form asks the patient to check all active diagnoses they have had in the last 7 days. It should be noted that the diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-10/J1750","prefix":"J1750","text":"Does the patient or resident have a history of falls, specifically, have they experienced two or more falls in the past year or any fall that resulted in injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}]},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Did the patient have any major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}]},{"linkId":"Section-11/K0110","prefix":"K0110","text":"Indicate the patient's usual ability to swallow by checking all applicable boxes pertaining to their swallowing and nutritional status.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}]},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Does the patient or resident have one or more unhealed pressure ulcers or injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"The form is asking the patient to report the number of Stage 2 pressure ulcers they currently have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"The patient has been asked to indicate the number of Stage 3 pressure ulcers they have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"The patient has a certain number of stage 4 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"How many unstageable pressure ulcers or injuries does the patient have due to a non-removable dressing or device?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"The form is asking the patient about the number of unstageable pressure ulcers they have due to the coverage of the wound bed by slough and/or eschar.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"The patient has a number of unstageable pressure injuries presenting as deep tissue injury.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"The form is asking the patient to disclose the number of Stage 1 pressure injuries they have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Did a complete drug regimen review conducted for the patient identify any potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}]},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Did the facility or setting contact a physician or a designated representative by midnight of the next calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues for the patient?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-15/O0100","prefix":"O0100","text":"The patient should check all of the following special treatments, procedures, and programs that were performed on them.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}]},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"The form for the patient includes sections such as the signature, title, and date section A that need to be completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"The patient must provide their signature, title, and date in the sections where the section completion is indicated by a 'B'.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"The sections labeled \"Signature\", \"Title\", \"Sections\", and \"Date Section Completed C\" must be filled out by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"The sections of the form completed by the patient are signed and dated, with their title also mentioned.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"The patient should fill out the signature, title, and sections, then indicate the date the section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"The patient's signature, title, and the date the form sections were completed are required in section F.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"The patient needs to provide their Signature, Title, and complete the Sections mentioned in the form, including the Date Section Completed G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"The patient needs to include their signature, title, and date on the completed sections H of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"The patient needs to provide their signature and title, complete the sections, and indicate the date on which the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"The patient is required to provide their signature, title, and the date on which the sections were completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature, their title, and fill out the sections on the form, indicating the date each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"The patient's form includes a signature, title, sections, and a section indicating the date the form was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100}],"_id":"CHjraSZxfiSSFsjpT"} {"responseType":"QuestionnaireResponse","id":"irf-pai-ia-3.0","questionnaire":"IRF-PAI-IA-3.0","title":"Inpatient Rehabilitation Facility Patient Assessment Instrument - IRF Admission","description":"Assessment data collected on all Medicare Part A fee-for-service patients who receive services under Part A from an inpatient rehabilitation facility (IRF) at admission and upon discharge.","status":"draft","authored":"2024-04-27T18:34:15.837Z","item":[{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0700","prefix":"A0700","text":"The patient should enter a \"+\" in the Medicaid Number field if the application is pending, or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-38/A0800","prefix":"A0800","text":"The patient's gender is required. Is the patient male or female?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Male"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Female"}}]},{"linkId":"Section-38/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/A1200","prefix":"A1200","text":"What is the patient's marital status? Is he/she single, married, divorced, separated, or widowed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Never married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Widowed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Separated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Divorced"}}]},{"linkId":"Section-38/A0220","prefix":"A0220","text":"What is the admission date for the patient?","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/11","prefix":"11","text":"What is the zip code of the patient's or resident's pre-hospital residence?","type":"text","repeats":false,"readOnly":false,"maxLength":5},{"linkId":"Section-38/13","prefix":"13","text":"The assessment reference date for the patient has been set.","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/14","prefix":"14","text":"The admission class of the patient is categorized under which category?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Initial Rehab"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Evaluation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Readmission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unplanned Discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Continuing Rehabilitation"}}]},{"linkId":"Section-38/17","prefix":"17","text":"Does the patient live at home prior to hospitalization? If the pre-hospital living setting is the patient's home, please code accordingly.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Alone"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Family / Relatives"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Friends"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Attendant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Other"}}]},{"linkId":"Section-38/15A","prefix":"15A","text":"From where was the patient admitted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}}]},{"linkId":"Section-38/16A","prefix":"16A","text":"The patient's pre-hospital living setting is required. Please use codes from the 'Admit From' category.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}}]},{"linkId":"Section-38/1A","prefix":"1A","text":"What is the name of the facility or provider for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":50},{"linkId":"Section-38/5B","prefix":"5B","text":"What is the patient's or resident's identification number?","type":"text","repeats":false,"readOnly":false,"maxLength":50},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Please check all the boxes that apply to the patient's race and ethnicity.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}]},{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Please record the most recent height measurement in inches for the patient since their admission.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"The patient's weight in pounds should be based on the most recent measure taken within the specified time period. The weight measurement must be executed consistently, adhering to the standard practice of the facility or setting, such as in the morning after voiding, before meals, with shoes off, etc.","type":"integer","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-41/21A","prefix":"21A","text":"The impairment group upon admission refers to the condition that required the patient to be admitted to rehabilitation; this should be coded according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-41/23","prefix":"23","text":"When did the impairment of the patient first begin?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Does the patient have any arthritis conditions recorded in either the impairment group, etiologic diagnosis, or comorbid conditions that meet all the regulatory requirements for Inpatient Rehabilitation Facility (IRF) classification?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-41/22A","prefix":"22A","text":"The form asks for the patient's etiologic diagnosis A.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/22B","prefix":"22B","text":"The form asks the patient for their etiologic diagnosis B.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/22C","prefix":"22C","text":"The form for the patient includes a section on etiologic diagnosis C.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24A","prefix":"24A","text":"Does the patient have Comorbid Condition A?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24B","prefix":"24B","text":"Does the patient have Comorbid Condition B?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24C","prefix":"24C","text":"Does the patient have Comorbid Condition C?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24D","prefix":"24D","text":"Does the patient have a comorbid condition D?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24E","prefix":"24E","text":"Does the patient have a comorbid condition E?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24F","prefix":"24F","text":"Does the patient have a comorbid condition F?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24G","prefix":"24G","text":"Does the patient have a comorbid condition G?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24H","prefix":"24H","text":"Does the patient have a comorbid condition H? Please select 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24I","prefix":"24I","text":"Does the patient have a comorbid condition? Please select either 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24J","prefix":"24J","text":"Does the patient have comorbid condition J?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24K","prefix":"24K","text":"Does the patient have a comorbid condition K?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24L","prefix":"24L","text":"Does the patient have any comorbid conditions? Please list them.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24M","prefix":"24M","text":"The patient has a comorbid condition labelled as M.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24N","prefix":"24N","text":"Does the patient have any comorbid conditions? Please select 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24O","prefix":"24O","text":"Does the patient have any comorbid conditions?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24P","prefix":"24P","text":"Does the patient have a comorbid condition P?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Does the patient have a comorbid condition?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24R","prefix":"24R","text":"Does the patient have a comorbid condition R?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24S","prefix":"24S","text":"The form inquires about the patient's comorbid conditions.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24T","prefix":"24T","text":"Does the patient have a comorbid condition? Please choose one: Yes or No.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24U","prefix":"24U","text":"The patient has a comorbid condition, referred to as Condition U.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24V","prefix":"24V","text":"Does the patient have a comorbid condition V?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24W","prefix":"24W","text":"Does the patient have a comorbid condition W?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24X","prefix":"24X","text":"Does the patient have a comorbid condition X?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Does the patient have a comorbid condition labeled as Y?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-40/20A","prefix":"20A","text":"The primary source of information about the patient is the patient themselves.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}]},{"linkId":"Section-40/20B","prefix":"20B","text":"The form asks the patient to provide a secondary source of information.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}]},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"The patient's ability to express ideas and wants, considering both verbal and non-verbal expression and excluding language barriers, is being evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}]},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Does the patient understand verbal and non-verbal content with the use of a hearing aid or device, excluding language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}]},{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should a brief interview for mental status be conducted? An attempt should be made to conduct an interview with all patients or residents.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-3/C0200","prefix":"C0200","text":"The form asks the patient: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" The form then records the number of words the patient repeated after the first attempt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}]},{"linkId":"Section-3/C0500","prefix":"C0500","text":"The BIMS Summary Score requires the addition of scores for the Brief Interview for Mental Status questions, with the total score filled in, ranging from 00-15. If the patient or resident was unable to complete the interview, enter 99.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the staff conduct an assessment for the patient's mental status?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}]},{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"The form asks the patient, \"Please tell me what year it is right now,\" to determine if they are able to accurately report the current year.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}]},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"The form asks the patient: \"What month are we in right now?\" The patient is expected to be able to report the correct month.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}]},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"The form asks the patient, \"What day of the week is today?\" The patient is then expected to be able to report the correct day of the week.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}]},{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"The patient is able to recall the word \"sock\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"The patient is able to recall the color \"blue\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Is the patient able to recall the word \"bed\"?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0900","prefix":"C0900","text":"The form asked to check all the items that the patient or resident was normally able to recall, indicating their memory or recall ability.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}]},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"The question on the form asks about the patient's ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them. This refers to their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"The patient's oral hygiene refers to their ability to use suitable items to clean their teeth. If applicable, their ability to handle dentures is evaluated by their capability to insert and remove them into and from the mouth, as well as successfully managing the soaking and rinsing of the dentures with the use of equipment. This is part of their admission performance assessment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"Does the patient have the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement? If the patient is managing an ostomy, does this include wiping the opening but not managing the equipment? Please assess their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"The discharge goal for the patient or resident is to gain the ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"The patient's oral hygiene pertains to their ability to use suitable items to clean their teeth. If applicable, their denture care involves the ability to insert and remove dentures into and from the mouth, as well as managing denture soaking and rinsing with the use of equipment. The discharge goal is to ensure these abilities.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"The discharge goal is for the patient to have the ability to maintain perineal hygiene, adjust their clothes before and after voiding or having a bowel movement. If they are managing an ostomy, this includes wiping the opening but not managing the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"The form asks about the patient's ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed during their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"The form asks about the patient's ability to move from sitting on the side of the bed to lying flat on the bed at the time of admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"The form asks about the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. This is referred to as 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"The discharge goal for the patient is to have the ability to roll from lying on their back to their left and right side, and then return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"The discharge goal for the patient includes the ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"The patient's discharge goal is the ability to move from lying on the back to sitting on the side of the bed without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"Does the patient have the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"The patient's admission performance includes the ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"The admission form poses a question regarding the patient's ability to transfer to and from a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"The question on the form asks about the patient's admission performance, specifically their ability to walk at least 10 feet in a room, corridor, or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"The form asks about the patient's admission performance, specifically their ability to walk at least 50 feet and make two turns once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"The form asks about the patient's admission performance, specifically, once standing, does the patient have the ability to walk at least 150 feet in a corridor or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"Once the patient is seated in the wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. This is a requirement for admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"The form asks about the patient's admission performance regarding their ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K3","prefix":"GG0170K3","text":"Does the patient have the ability, once standing, to walk at least 150 feet in a corridor or similar space? This will be evaluated as part of their discharge performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"The discharge goal for the patient is to develop the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"The discharge goal for the patient is to be able to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"The discharge goal for the patient is to have the ability to get on and off a toilet or commode independently.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"The discharge goal for the patient is to achieve the ability to walk at least 10 feet once standing, whether it's in a room, corridor, or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"The form asks if, once standing, the patient has the ability to walk at least 50 feet and make two turns. The answer options for this question are \"Yes\" or \"No\". This information will help set a discharge goal for the patient.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"The form inquires if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The goal is to attain this ability by the time of discharge.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"The discharge goal for the patient is to be able once seated in the wheelchair or scooter, to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"The discharge goal for the patient is to have the ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the patient or resident use a wheelchair and/or scooter upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Please indicate the type of wheelchair or scooter that the patient uses upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"The patient is required to indicate the type of wheelchair or scooter used upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"The form inquires about the patient's ability to bathe themselves, which includes washing, rinsing, and drying themselves, excluding washing of the back and hair. It does not consider the ability to transfer in or out of the tub or shower. This information is required for the Admission Performance assessment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"The admission performance form inquires about the patient's ability to dress and undress above the waist, including the handling of fasteners if applicable, under the section labeled 'Upper Body Dressing'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"On the admission form, it asks about the patient's ability to dress and undress below the waist, including handling fasteners. It does not include dealing with footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"The form asks about the patient's ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable. This is in reference to their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"The form asks about the patient's ability to transfer in and out of a car or van from the passenger side upon admission. This does not include the patient's ability to open or close the door or fasten their seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"The form asks about the patient's ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel, in terms of their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"The form asks about the patient's ability to go up and down a curb and/or up and down one step, as a measure of their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170N1","prefix":"GG0170N1","text":"The patient's admission performance indicates their ability to go up and down four steps, either with or without the aid of a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170O1","prefix":"GG0170O1","text":"The question on the form asks about the patient's ability to go up and down 12 steps with or without a rail. The label is \"Admission Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170P1","prefix":"GG0170P1","text":"The form asks about the patient's ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor. This question is referred to as the 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130E2","prefix":"GG0130E2","text":"The form asks about the patient's ability to shower or bathe themselves, which includes washing, rinsing, and drying, but excludes washing of the back and hair. It is important to note, this does not include the patient's ability to transfer in and out of the tub or shower. The focus of this question is to understand the patient's discharge goal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130F2","prefix":"GG0130F2","text":"The patient's discharge goal includes developing the ability to dress and undress themselves above the waist, including managing fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130G2","prefix":"GG0130G2","text":"The discharge goal for the patient is to develop the ability to dress and undress below the waist, including handling fasteners, but this does not include managing footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130H2","prefix":"GG0130H2","text":"The discharge goal for the patient is to develop the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including managing fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"The patient's discharge goal is to be able to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten the seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"The patient's discharge goal is to have the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoors or outdoors.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"The discharge goal for the patient is the ability to go up and down a curb and/or up and down one step.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"The discharge goal for the patient is to develop the ability to go up and down four steps, with or without the assistance of a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"The discharge goal for the patient is to have the ability to go up and down 12 steps with or without a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"The discharge goal for the patient is to develop the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Please code the patient's or resident's need for assistance with activities such as bathing, dressing, using the toilet, and eating prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"The form asks for the patient's or resident's level of need for assistance with indoor mobility, specifically walking from room to room, prior to the current illness, exacerbation, or injury. This includes whether they required a device such as a cane, crutch, or walker.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Please code the patient's or resident's need for assistance with internal or external stairs, whether with or without a device such as a cane, crutch, or walker, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Please code the patient's need for assistance with planning regular tasks, such as shopping or remembering to take medication, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"The form asks for information about the devices and aids that the patient or resident was using prior to their current illness, exacerbation, or injury. It requests that all applicable options be checked.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Please select the category that best describes the bowel continence of the patient or resident.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}]},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Please select the one category that best describes the patient's bladder continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}]},{"linkId":"Section-9/I0000","prefix":"I0000","text":"The form asks the patient to check all active diagnoses they have had in the last 7 days. It should be noted that the diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-10/J1750","prefix":"J1750","text":"Does the patient or resident have a history of falls, specifically, have they experienced two or more falls in the past year or any fall that resulted in injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}]},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Did the patient have any major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}]},{"linkId":"Section-11/K0110","prefix":"K0110","text":"Indicate the patient's usual ability to swallow by checking all applicable boxes pertaining to their swallowing and nutritional status.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}]},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Does the patient or resident have one or more unhealed pressure ulcers or injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"The form is asking the patient to report the number of Stage 2 pressure ulcers they currently have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"The patient has been asked to indicate the number of Stage 3 pressure ulcers they have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"The patient has a certain number of stage 4 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"How many unstageable pressure ulcers or injuries does the patient have due to a non-removable dressing or device?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"The form is asking the patient about the number of unstageable pressure ulcers they have due to the coverage of the wound bed by slough and/or eschar.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"The patient has a number of unstageable pressure injuries presenting as deep tissue injury.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"The form is asking the patient to disclose the number of Stage 1 pressure injuries they have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Did a complete drug regimen review conducted for the patient identify any potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}]},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Did the facility or setting contact a physician or a designated representative by midnight of the next calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues for the patient?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-15/O0100","prefix":"O0100","text":"The patient should check all of the following special treatments, procedures, and programs that were performed on them.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}]},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"The form for the patient includes sections such as the signature, title, and date section A that need to be completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"The patient must provide their signature, title, and date in the sections where the section completion is indicated by a 'B'.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"The sections labeled \"Signature\", \"Title\", \"Sections\", and \"Date Section Completed C\" must be filled out by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"The sections of the form completed by the patient are signed and dated, with their title also mentioned.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"The patient should fill out the signature, title, and sections, then indicate the date the section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"The patient's signature, title, and the date the form sections were completed are required in section F.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"The patient needs to provide their Signature, Title, and complete the Sections mentioned in the form, including the Date Section Completed G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"The patient needs to include their signature, title, and date on the completed sections H of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"The patient needs to provide their signature and title, complete the sections, and indicate the date on which the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"The patient is required to provide their signature, title, and the date on which the sections were completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature, their title, and fill out the sections on the form, indicating the date each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"The patient's form includes a signature, title, sections, and a section indicating the date the form was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100}],"_id":"frk6qmZBzmehZLZPL"} {"id":"pbupcoBuWyD8N7qtY","responseType":"QuestionnaireResponse","status":"draft","authored":"2024-04-27T18:36:21.698Z","item":[{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0800","prefix":"A0800","text":"What is the patient's gender?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Female"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}]},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1100B","prefix":"A1100B","text":"What is the patient's preferred language?","type":"text","repeats":false,"readOnly":false,"maxLength":15},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"The form for the patient asks for their suffix.","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"What is the patient's National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-3/C1610E1","prefix":"C1610E1","text":"The patient's alertness level is normal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the patient or resident use a wheelchair and/or scooter upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"How many Stage 1 pressure injuries does the patient have?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"The patient has a certain number of stage 4 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0200","prefix":"A0200","text":"The type of provider for the patient needs to be specified.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Long-Term Care Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28448-1","display":"Long-term care hospital "}}]},{"linkId":"Section-15/O0250B","prefix":"O0250B","text":"What is the date the patient received the influenza vaccine?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0100C","prefix":"A0100C","text":"The patient's State Medicaid Facility or Provider Number is required.","type":"text","repeats":false,"readOnly":false,"maxLength":15},{"linkId":"Section-9/I0050","prefix":"I0050","text":"Please indicate the primary medical condition category for the patient or resident.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Acute Onset Respiratory Condition (e.g., aspiration and specified bacterial pneumonias)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27513-3","display":"Acute onset respiratory condition (e.g., aspiration and specified bacterial pneumonias)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Chronic Respiratory Condition (e.g., chronic obstructive pulmonary disease)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27514-1","display":"Chronic respiratory condition (e.g., chronic obstructive pulmonary disease)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Acute Onset and Chronic Respiratory Conditions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27515-8","display":"Acute onset and chronic respiratory conditions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Chronic Cardiac Condition (e.g., heart failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27516-6","display":"Chronic cardiac condition (e.g., heart failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Other Medical Condition. If \"Other Medical Condition\", enter ICD code in the boxes."}},{"valueCoding":{"system":"http://loinc.org","code":"LA16346-1","display":"Other medical condition"}}]},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"The patient has a certain number of Stage 2 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0210","prefix":"A0210","text":"The assessment reference date refers to the patient's observation end date.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1400","prefix":"A1400","text":"The patient needs to provide their payer information by checking all the boxes that apply.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Medicare (traditional fee-for-service)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6259-1","display":"Medicare (traditional fee-for-service)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Medicare (managed care/Part C/Medicare Advantage)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27554-7","display":"Medicare (managed care/Part C/Medicare Advantage)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Medicaid (traditional fee-for-service)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6257-5","display":"Medicaid (traditional fee-for-service)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Medicaid (managed care)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27556-2","display":"Medicaid (managed care)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Workers' compensation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6452-2","display":"Workers' compensation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Title programs (e.g., Title III, V, or XX)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6398-7","display":"Title programs (e.g., Title III, V, or XX)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Other government (e.g., TRICARE, VA, etc.)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10049-7","display":"Other government (e.g., TRICARE, VA, etc.)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Private insurance/Medigap"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10061-2","display":"Private insurance/Medigap"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Private managed care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27561-2","display":"Private managed care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Self-pay"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6369-8","display":"Self-pay"}},{"valueCoding":{"system":"http://del.cms.gov","code":"K","display":"No payer source"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18995-3","display":"No payor source"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"Other"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}]},{"linkId":"Section-15/O0100","prefix":"O0100","text":"Please check all of the following special treatments, procedures, and programs that were performed on the patient.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Non-invasive Ventilator (BIPAP, CPAP)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27542-2","display":"Non-invasive ventilator (BIPAP, CPAP)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"IV Medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27972-1","display":"IV medications, (if checked, please specify below)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H2a","display":"Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28269-1","display":"Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Dialysis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA7216-0","display":"Dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-36/A0250","prefix":"A0250","text":"What is the reason for the patient's assessment?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Admission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10922-5","display":"Admission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Planned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18067-1","display":"Planned discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"12","display":"Expired"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10325-1","display":"Expired"}}]},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record for the patient needs to be identified.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Add new assessment/record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27573-7","display":"Add new assessment/record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Modify existing record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12664-1","display":"Modify existing record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Inactivate existing record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12665-8","display":"Inactivate existing record"}}]},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"The sections were completed and dated by the patient, who then signed and titled the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"The patient has a certain number of unstageable pressure injuries that are presenting as deep tissue injury.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Where was the patient immediately preceding this admission? Was the patient admitted from home, another healthcare facility, or somewhere else?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11501-6","display":"Community residential setting (e.g., private home, assisted living, group home, adult foster care)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Long-term care facility (LTC)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18066-3","display":"Long-term care facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Hospital emergency department"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11504-0","display":"Hospital emergency department"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Short-stay acute hospital (IPPS)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10078-6","display":"Short-stay acute hospital (IPPS)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"Inpatient rehabilitation facility or unit (IRF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27548-9","display":"Inpatient rehabilitation facility or unit (IRF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"Psychiatric hospital or unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10065-3","display":"Psychiatric hospital or unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Intellectually Disabled/Developmentally Disabled (ID/DD) facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28224-6","display":"Intellectually disabled/developmentally disabled (ID/DD) facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Hospice"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6216-1","display":"Hospice"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-15/O0250A","prefix":"O0250A","text":"Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"The patient must provide their signature, title, and the date on which they completed Section I of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"The patient needs to provide their Signature, Title, and the Date they completed Section D.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-2/B0100","prefix":"B0100","text":"The patient is in a comatose state with no discernible consciousness, persisting in a vegetative state.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Please select the one category that best describes the patient's bladder continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}]},{"linkId":"Section-3/C1610A","prefix":"C1610A","text":"Is there evidence of an acute change in the patient's or resident's mental status from their baseline?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Did a complete drug regimen review for the patient identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}]},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Does the patient understand both verbal and non-verbal content with the use of their hearing aid or device, excluding any language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}]},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Does the patient express their ideas and wants, considering both verbal and non-verbal expression and excluding language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}]},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"The discharge goal for the patient is to have the ability to get on and off a toilet or commode independently.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"The form asks about the patient's admission performance regarding their ability to transfer to and from a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-36/A1200","prefix":"A1200","text":"What is the patient's marital status? Is the patient single, married, divorced, separated, or widowed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Divorced"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}]},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"The discharge goal for the patient is to have the ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0500B","prefix":"Z0500B","text":"The date on which the Registered Nurse Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-15/O0150B","prefix":"O0150B","text":"The patient was assessed for readiness for spontaneous breathing trial (SBT) by the second day of their Long Term Care Hospital (LTCH) stay.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Does this patient or resident have one or more unhealed pressure ulcers or injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"The signature, title, and date of the section completed F were filled out by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-36/A1100A","prefix":"A1100A","text":"Does the patient need or want an interpreter to communicate with a doctor or health care staff? Please indicate 'yes' or 'no'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Unable to determine"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11137-9","display":"Unable to determine"}}]},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"The patient completed section B and then they signed and dated the form, also providing their title.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-15/O0150A","prefix":"O0150A","text":"Was the patient on invasive mechanical ventilator support upon admission to the Long-Term Care Hospital?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No, not on invasive mechanical ventilation support upon admission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28329-3","display":"No, not on invasive mechanical ventilation support"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, weaning"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28330-1","display":"Yes, weaning"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, non-weaning"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28331-9","display":"Yes, non-weaning"}}]},{"linkId":"Section-9/I0050A","prefix":"I0050A","text":"If the patient has an \"Other Medical Condition\", they should enter the ICD code in the provided boxes.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"How many unstageable pressure ulcers does the patient have due to the coverage of the wound bed by slough and/or eschar?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"The patient's signature, title, and the date are required in the completed Section G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"The form requires the patient's signature, title, the sections they completed, and the date on which Section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-11/K0200A","prefix":"K0200A","text":"Please record the most recent measurement of the patient's height in inches since their admission.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"The admission date of the patient is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-19/Z0500A","prefix":"Z0500A","text":"The form requires the patient's signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Please select the one category that best describes the patient's or resident's bowel continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}]},{"linkId":"Section-36/A1000","prefix":"A1000","text":"The patient should check all the applicable options for their race or ethnicity.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}]},{"linkId":"Section-3/C1610B","prefix":"C1610B","text":"Did the patient's abnormal behavior fluctuate during the day, that is, did it tend to come and go or increase and decrease in severity?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title in the designated sections and also indicate the date when each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"The form asks if, once standing, the patient has the ability to walk at least 50 feet and make two turns for their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"How many Stage 3 pressure ulcers does the patient have?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"The form asks about the patient's admission performance regarding their ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"The form asks about the patient's admission performance in regards to their ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"The discharge goal for the patient is to gain the ability to stand up and walk at least 10 feet in a room, corridor, or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"The form asks about the patient's admission performance in terms of their ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-3/C1610E2","prefix":"C1610E2","text":"Is the patient vigilant (hyperalert), lethargic (drowsy, easily aroused), in a stupor (difficult to arouse), or in a coma (unarousable)?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature and title, and complete the relevant sections. The date when the section was completed is also required.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"The discharge goal for the patient is to achieve the ability to walk at least 150 feet in a corridor or similar space, once they are able to stand.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"The patient must provide their signature and title, as well as complete the sections indicated. The date when the section was completed has to be marked as 'A'.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0130D1","prefix":"GG0130D1","text":"The admission performance form inquires about the patient's ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"The form asks about the patient's admission performance, specifically inquiring about their ability to stand and walk at least 150 feet in a corridor or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"The discharge goal for the patient or resident is to gain the ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"The discharge goal for the patient is to once be seated in a wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"The form asks about the patient's admission performance, specifically whether, once seated in a wheelchair or scooter, they are able to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"The section labeled \"Signature, Title, Sections, Date Section Completed L\" on the patient's form needs to be filled out.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"How many unstageable pressure ulcers or injuries does the patient have due to a non-removable dressing or device?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-15/O0150C","prefix":"O0150C","text":"The patient was deemed medically ready for Spontaneous Breathing Trial (SBT) by day 2 of their Long Term Care Hospital (LTCH) stay.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"The form asks about the patient's admission performance in relation to their ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-9/I0000","prefix":"I0000","text":"Has the patient had any active diagnoses in the last 7 days? Please check all that apply. The diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0103","display":"Metastatic Cancer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28289-9","display":"Metastatic cancer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0104","display":"Severe Cancer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28290-7","display":"Severe cancer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0605","display":"Severe Left Systolic/Ventricular Dysfunction (known ejection fraction <= 30%)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28298-0","display":"Severe left systolic/ventricular dysfunction (known ejection fraction <= 30%)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1501","display":"Chronic Kidney Disease, Stage 5"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27518-2","display":"Chronic kidney disease, stage 5"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1502","display":"Acute Renal Failure"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27519-0","display":"Acute renal failure"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2101","display":"Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27520-8","display":"Septicemia, sepsis, systemic inflammatory response syndrome/shock"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2600","display":"Central Nervous System Infections, Opportunistic Infections, Bone/Joint/Muscle Infections/Necrosis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27521-6","display":"Central nervous system infections, opportunistic infections, bone/joint/muscle infections/necrosis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27539-8","display":"Diabetes mellitus (DM)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4100","display":"Major Lower Limb Amputation (e.g., above knee, below knee)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27522-4","display":"Major lower limb amputation (e.g., above knee, below knee)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4501","display":"Stroke"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22099-8","display":"Stroke"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4801","display":"Dementia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA20372-1","display":"Dementia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4900","display":"Hemiplegia or Hemiparesis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27523-2","display":"Hemiplegia or hemiparesis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5000","display":"Paraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA25276-9","display":"Paraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5101","display":"Complete Tetraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27528-1","display":"Complete tetraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5102","display":"Incomplete Tetraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27529-9","display":"Incomplete tetraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5110","display":"Other Spinal Cord Disorder/Injury (e.g., myelitis, cauda equina syndrome)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27530-7","display":"Other spinal cord disorder/injury (e.g., myelitis, cauda equina syndrome)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5200","display":"Multiple Sclerosis (MS)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27531-5","display":"Multiple sclerosis (MS)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5250","display":"Huntington's Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27532-3","display":"Huntington's disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5300","display":"Parkinson's Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27533-1","display":"Parkinson's disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5450","display":"Amyotrophic Lateral Sclerosis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27534-9","display":"Amyotrophic lateral sclerosis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5455","display":"Other Progressive Neuromuscular Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28291-5","display":"Other progressive neuromuscular disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5460","display":"Locked-In State"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27535-6","display":"Locked-in state"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5470","display":"Severe Anoxic Brain Damage, Cerebral Edema, or Compression of Brain"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27536-4","display":"Severe anoxic brain damage, cerebral edema, or compression of brain"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5480","display":"Other Severe Neurological Injury, Disease, or Dysfunction"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28292-3","display":"Other severe neurological injury, disease, or dysfunction"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5601","display":"Malnutrition (protein or calorie)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27537-2","display":"Malnutrition (protein or calorie)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5602","display":"At Risk for Malnutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27538-0","display":"At risk for malnutrition"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7100","display":"Lung Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28293-1","display":"Lung transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7101","display":"Heart Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28294-9","display":"Heart transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7102","display":"Liver Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28295-6","display":"Liver transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7103","display":"Kidney Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28296-4","display":"Kidney transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7104","display":"Bone Marrow Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28297-2","display":"Bone marrow transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-36/A0700","prefix":"A0700","text":"The patient should enter a \"+\" in the Medicaid Number section if their Medicaid application is pending, or \"N\" if they are not a recipient of Medicaid.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"The discharge goal for the patient pertains to their ability to transfer to and from a bed to a chair, which could also include a wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"The discharge goal for the patient is the ability to transition from lying on their back to sitting on the side of the bed without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Please code the patient's or resident's need for assistance with walking from room to room, with or without a device such as a cane, crutch, or walker, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - a helper completed the activity for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-3/C1610D","prefix":"C1610D","text":"Was the patient's or resident's thinking disorganized or incoherent, characterized by rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switches from subject to subject?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"The discharge goal for the patient is to attain the ability to stand and walk at least 50 feet, making two turns once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"The sections of the form, including the signature and title sections, were completed by the patient on the date indicated in the \"Date Section Completed H\".","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Does the patient have the ability to walk at least 10 feet in a room, corridor, or similar space once they are standing? Select from the following options for their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Did the facility or setting contact a physician, or the physician's designee, by midnight of the next calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"The discharge goal for the patient pertains to their ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, which is referred to as \"sit to stand\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"The discharge goal for the patient includes their ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If they are managing an ostomy, this will also include wiping the opening, but not managing the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"The form is questioning the patient's ability, once seated in a wheelchair or scooter, to wheel at least 150 feet in a corridor or similar space. This is a discharge goal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-3/C1610C","prefix":"C1610C","text":"Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? The possible answers could be 'Yes', 'No', or 'Sometimes'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-15/O0150D","prefix":"O0150D","text":"Is there documentation of the reason or reasons in the patient's or resident's medical record that indicates why the patient or resident was deemed medically unready for SBT by the second day of their stay at the Long-Term Care Hospital?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0130D2","prefix":"GG0130D2","text":"The discharge goal for the patient is to have the ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-15/O0250C","prefix":"O0250C","text":"If the patient has not received the influenza vaccine, please state the reason. The options may include: a) allergic to the vaccine, b) vaccine not available, c) personal beliefs, or d) other reasons.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"{Patient/resident} not in facility during this year's influenza vaccination season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26745-2","display":"Patient not in this facility during this year's influenza vaccination season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Received outside of this facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA184-4","display":"Received outside of this facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Not eligible - medical contraindication"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11091-8","display":"Not eligible - medical contraindication"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Offered and declined"}},{"valueCoding":{"system":"http://loinc.org","code":"LA186-9","display":"Offered and declined"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Not offered"}},{"valueCoding":{"system":"http://loinc.org","code":"LA187-7","display":"Not offered"}},{"valueCoding":{"system":"http://del.cms.gov","code":"6","display":"Inability to obtain influenza vaccine due to a declared shortage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26746-0","display":"Inability to obtain influenza vaccine due to a declared shortage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"The question on the form refers to the patient or resident's eating abilities, specifically their ability to utilize appropriate utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is presented to them. This is evaluated based on their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-15/O0150E","prefix":"O0150E","text":"If the patient or resident was deemed medically ready for a Spontaneous Breathing Trial (SBT), was the SBT performed by the second day of their Long Term Care Hospital (LTCH) stay?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"The question on the form assesses the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. The label for this section is 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"The patient's admission performance is evaluated based on their ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If the patient is managing an ostomy, the evaluation includes their ability to wipe the opening but not manage the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"The discharge goal for the patient is to have the ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"The patient's oral hygiene refers to their ability to use suitable items to clean their teeth. If applicable, the patient's ability to handle dentures includes inserting and removing dentures from their mouth and managing denture soaking and rinsing with the use of equipment. The discharge goal needs to be determined.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-11/K0200B","prefix":"K0200B","text":"The patient's weight in pounds should be based on the most recent measure taken in the last specified number of days. The weight must be measured consistently, in accordance with the standard practice of the facility or setting, which may include measurements in the morning after voiding, before meals, with shoes off, etc.","type":"integer","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"The form inquires about the patient's admission performance concerning their ability to roll from lying on their back to their left and right side, and then return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"The patient's oral hygiene pertains to their ability to use suitable items to clean their teeth. If applicable, their use of dentures involves their ability to insert and remove dentures into and from the mouth, as well as manage denture soaking and rinsing with the use of equipment. This information was gathered from their performance upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Please indicate the devices and aids that the patient or resident had used prior to their current illness, exacerbation, or injury. Check all that apply.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]}],"_id":"uKky8mSqXLxuq6muA"} {"id":"pbupcoBuWyD8N7qtY","responseType":"QuestionnaireResponse","status":"draft","authored":"2024-04-27T18:36:21.698Z","item":[{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0800","prefix":"A0800","text":"What is the patient's gender?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Female"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}]},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1100B","prefix":"A1100B","text":"What is the patient's preferred language?","type":"text","repeats":false,"readOnly":false,"maxLength":15},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"The form for the patient asks for their suffix.","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"What is the patient's National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-3/C1610E1","prefix":"C1610E1","text":"The patient's alertness level is normal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the patient or resident use a wheelchair and/or scooter upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"How many Stage 1 pressure injuries does the patient have?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"The patient has a certain number of stage 4 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0200","prefix":"A0200","text":"The type of provider for the patient needs to be specified.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Long-Term Care Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28448-1","display":"Long-term care hospital "}}]},{"linkId":"Section-15/O0250B","prefix":"O0250B","text":"What is the date the patient received the influenza vaccine?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0100C","prefix":"A0100C","text":"The patient's State Medicaid Facility or Provider Number is required.","type":"text","repeats":false,"readOnly":false,"maxLength":15},{"linkId":"Section-9/I0050","prefix":"I0050","text":"Please indicate the primary medical condition category for the patient or resident.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Acute Onset Respiratory Condition (e.g., aspiration and specified bacterial pneumonias)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27513-3","display":"Acute onset respiratory condition (e.g., aspiration and specified bacterial pneumonias)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Chronic Respiratory Condition (e.g., chronic obstructive pulmonary disease)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27514-1","display":"Chronic respiratory condition (e.g., chronic obstructive pulmonary disease)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Acute Onset and Chronic Respiratory Conditions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27515-8","display":"Acute onset and chronic respiratory conditions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Chronic Cardiac Condition (e.g., heart failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27516-6","display":"Chronic cardiac condition (e.g., heart failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Other Medical Condition. If \"Other Medical Condition\", enter ICD code in the boxes."}},{"valueCoding":{"system":"http://loinc.org","code":"LA16346-1","display":"Other medical condition"}}]},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"The patient has a certain number of Stage 2 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0210","prefix":"A0210","text":"The assessment reference date refers to the patient's observation end date.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1400","prefix":"A1400","text":"The patient needs to provide their payer information by checking all the boxes that apply.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Medicare (traditional fee-for-service)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6259-1","display":"Medicare (traditional fee-for-service)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Medicare (managed care/Part C/Medicare Advantage)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27554-7","display":"Medicare (managed care/Part C/Medicare Advantage)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Medicaid (traditional fee-for-service)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6257-5","display":"Medicaid (traditional fee-for-service)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Medicaid (managed care)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27556-2","display":"Medicaid (managed care)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Workers' compensation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6452-2","display":"Workers' compensation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Title programs (e.g., Title III, V, or XX)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6398-7","display":"Title programs (e.g., Title III, V, or XX)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Other government (e.g., TRICARE, VA, etc.)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10049-7","display":"Other government (e.g., TRICARE, VA, etc.)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Private insurance/Medigap"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10061-2","display":"Private insurance/Medigap"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Private managed care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27561-2","display":"Private managed care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Self-pay"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6369-8","display":"Self-pay"}},{"valueCoding":{"system":"http://del.cms.gov","code":"K","display":"No payer source"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18995-3","display":"No payor source"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"Other"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}]},{"linkId":"Section-15/O0100","prefix":"O0100","text":"Please check all of the following special treatments, procedures, and programs that were performed on the patient.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Non-invasive Ventilator (BIPAP, CPAP)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27542-2","display":"Non-invasive ventilator (BIPAP, CPAP)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"IV Medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27972-1","display":"IV medications, (if checked, please specify below)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H2a","display":"Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28269-1","display":"Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Dialysis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA7216-0","display":"Dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-36/A0250","prefix":"A0250","text":"What is the reason for the patient's assessment?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Admission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10922-5","display":"Admission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Planned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18067-1","display":"Planned discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"12","display":"Expired"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10325-1","display":"Expired"}}]},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record for the patient needs to be identified.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Add new assessment/record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27573-7","display":"Add new assessment/record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Modify existing record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12664-1","display":"Modify existing record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Inactivate existing record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12665-8","display":"Inactivate existing record"}}]},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"The sections were completed and dated by the patient, who then signed and titled the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"The patient has a certain number of unstageable pressure injuries that are presenting as deep tissue injury.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Where was the patient immediately preceding this admission? Was the patient admitted from home, another healthcare facility, or somewhere else?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11501-6","display":"Community residential setting (e.g., private home, assisted living, group home, adult foster care)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Long-term care facility (LTC)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18066-3","display":"Long-term care facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Hospital emergency department"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11504-0","display":"Hospital emergency department"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Short-stay acute hospital (IPPS)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10078-6","display":"Short-stay acute hospital (IPPS)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"Inpatient rehabilitation facility or unit (IRF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27548-9","display":"Inpatient rehabilitation facility or unit (IRF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"Psychiatric hospital or unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10065-3","display":"Psychiatric hospital or unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Intellectually Disabled/Developmentally Disabled (ID/DD) facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28224-6","display":"Intellectually disabled/developmentally disabled (ID/DD) facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Hospice"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6216-1","display":"Hospice"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-15/O0250A","prefix":"O0250A","text":"Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"The patient must provide their signature, title, and the date on which they completed Section I of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"The patient needs to provide their Signature, Title, and the Date they completed Section D.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-2/B0100","prefix":"B0100","text":"The patient is in a comatose state with no discernible consciousness, persisting in a vegetative state.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Please select the one category that best describes the patient's bladder continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}]},{"linkId":"Section-3/C1610A","prefix":"C1610A","text":"Is there evidence of an acute change in the patient's or resident's mental status from their baseline?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Did a complete drug regimen review for the patient identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}]},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Does the patient understand both verbal and non-verbal content with the use of their hearing aid or device, excluding any language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}]},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Does the patient express their ideas and wants, considering both verbal and non-verbal expression and excluding language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}]},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"The discharge goal for the patient is to have the ability to get on and off a toilet or commode independently.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"The form asks about the patient's admission performance regarding their ability to transfer to and from a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-36/A1200","prefix":"A1200","text":"What is the patient's marital status? Is the patient single, married, divorced, separated, or widowed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Divorced"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}]},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"The discharge goal for the patient is to have the ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0500B","prefix":"Z0500B","text":"The date on which the Registered Nurse Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-15/O0150B","prefix":"O0150B","text":"The patient was assessed for readiness for spontaneous breathing trial (SBT) by the second day of their Long Term Care Hospital (LTCH) stay.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Does this patient or resident have one or more unhealed pressure ulcers or injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"The signature, title, and date of the section completed F were filled out by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-36/A1100A","prefix":"A1100A","text":"Does the patient need or want an interpreter to communicate with a doctor or health care staff? Please indicate 'yes' or 'no'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Unable to determine"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11137-9","display":"Unable to determine"}}]},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"The patient completed section B and then they signed and dated the form, also providing their title.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-15/O0150A","prefix":"O0150A","text":"Was the patient on invasive mechanical ventilator support upon admission to the Long-Term Care Hospital?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No, not on invasive mechanical ventilation support upon admission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28329-3","display":"No, not on invasive mechanical ventilation support"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, weaning"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28330-1","display":"Yes, weaning"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, non-weaning"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28331-9","display":"Yes, non-weaning"}}]},{"linkId":"Section-9/I0050A","prefix":"I0050A","text":"If the patient has an \"Other Medical Condition\", they should enter the ICD code in the provided boxes.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"How many unstageable pressure ulcers does the patient have due to the coverage of the wound bed by slough and/or eschar?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"The patient's signature, title, and the date are required in the completed Section G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"The form requires the patient's signature, title, the sections they completed, and the date on which Section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-11/K0200A","prefix":"K0200A","text":"Please record the most recent measurement of the patient's height in inches since their admission.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"The admission date of the patient is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-19/Z0500A","prefix":"Z0500A","text":"The form requires the patient's signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Please select the one category that best describes the patient's or resident's bowel continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}]},{"linkId":"Section-36/A1000","prefix":"A1000","text":"The patient should check all the applicable options for their race or ethnicity.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}]},{"linkId":"Section-3/C1610B","prefix":"C1610B","text":"Did the patient's abnormal behavior fluctuate during the day, that is, did it tend to come and go or increase and decrease in severity?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title in the designated sections and also indicate the date when each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"The form asks if, once standing, the patient has the ability to walk at least 50 feet and make two turns for their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"How many Stage 3 pressure ulcers does the patient have?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"The form asks about the patient's admission performance regarding their ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"The form asks about the patient's admission performance in regards to their ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"The discharge goal for the patient is to gain the ability to stand up and walk at least 10 feet in a room, corridor, or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"The form asks about the patient's admission performance in terms of their ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-3/C1610E2","prefix":"C1610E2","text":"Is the patient vigilant (hyperalert), lethargic (drowsy, easily aroused), in a stupor (difficult to arouse), or in a coma (unarousable)?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature and title, and complete the relevant sections. The date when the section was completed is also required.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"The discharge goal for the patient is to achieve the ability to walk at least 150 feet in a corridor or similar space, once they are able to stand.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"The patient must provide their signature and title, as well as complete the sections indicated. The date when the section was completed has to be marked as 'A'.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0130D1","prefix":"GG0130D1","text":"The admission performance form inquires about the patient's ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"The form asks about the patient's admission performance, specifically inquiring about their ability to stand and walk at least 150 feet in a corridor or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"The discharge goal for the patient or resident is to gain the ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"The discharge goal for the patient is to once be seated in a wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"The form asks about the patient's admission performance, specifically whether, once seated in a wheelchair or scooter, they are able to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"The section labeled \"Signature, Title, Sections, Date Section Completed L\" on the patient's form needs to be filled out.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"How many unstageable pressure ulcers or injuries does the patient have due to a non-removable dressing or device?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-15/O0150C","prefix":"O0150C","text":"The patient was deemed medically ready for Spontaneous Breathing Trial (SBT) by day 2 of their Long Term Care Hospital (LTCH) stay.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"The form asks about the patient's admission performance in relation to their ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-9/I0000","prefix":"I0000","text":"Has the patient had any active diagnoses in the last 7 days? Please check all that apply. The diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0103","display":"Metastatic Cancer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28289-9","display":"Metastatic cancer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0104","display":"Severe Cancer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28290-7","display":"Severe cancer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0605","display":"Severe Left Systolic/Ventricular Dysfunction (known ejection fraction <= 30%)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28298-0","display":"Severe left systolic/ventricular dysfunction (known ejection fraction <= 30%)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1501","display":"Chronic Kidney Disease, Stage 5"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27518-2","display":"Chronic kidney disease, stage 5"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1502","display":"Acute Renal Failure"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27519-0","display":"Acute renal failure"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2101","display":"Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27520-8","display":"Septicemia, sepsis, systemic inflammatory response syndrome/shock"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2600","display":"Central Nervous System Infections, Opportunistic Infections, Bone/Joint/Muscle Infections/Necrosis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27521-6","display":"Central nervous system infections, opportunistic infections, bone/joint/muscle infections/necrosis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27539-8","display":"Diabetes mellitus (DM)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4100","display":"Major Lower Limb Amputation (e.g., above knee, below knee)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27522-4","display":"Major lower limb amputation (e.g., above knee, below knee)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4501","display":"Stroke"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22099-8","display":"Stroke"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4801","display":"Dementia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA20372-1","display":"Dementia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4900","display":"Hemiplegia or Hemiparesis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27523-2","display":"Hemiplegia or hemiparesis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5000","display":"Paraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA25276-9","display":"Paraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5101","display":"Complete Tetraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27528-1","display":"Complete tetraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5102","display":"Incomplete Tetraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27529-9","display":"Incomplete tetraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5110","display":"Other Spinal Cord Disorder/Injury (e.g., myelitis, cauda equina syndrome)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27530-7","display":"Other spinal cord disorder/injury (e.g., myelitis, cauda equina syndrome)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5200","display":"Multiple Sclerosis (MS)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27531-5","display":"Multiple sclerosis (MS)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5250","display":"Huntington's Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27532-3","display":"Huntington's disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5300","display":"Parkinson's Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27533-1","display":"Parkinson's disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5450","display":"Amyotrophic Lateral Sclerosis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27534-9","display":"Amyotrophic lateral sclerosis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5455","display":"Other Progressive Neuromuscular Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28291-5","display":"Other progressive neuromuscular disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5460","display":"Locked-In State"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27535-6","display":"Locked-in state"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5470","display":"Severe Anoxic Brain Damage, Cerebral Edema, or Compression of Brain"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27536-4","display":"Severe anoxic brain damage, cerebral edema, or compression of brain"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5480","display":"Other Severe Neurological Injury, Disease, or Dysfunction"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28292-3","display":"Other severe neurological injury, disease, or dysfunction"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5601","display":"Malnutrition (protein or calorie)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27537-2","display":"Malnutrition (protein or calorie)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5602","display":"At Risk for Malnutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27538-0","display":"At risk for malnutrition"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7100","display":"Lung Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28293-1","display":"Lung transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7101","display":"Heart Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28294-9","display":"Heart transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7102","display":"Liver Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28295-6","display":"Liver transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7103","display":"Kidney Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28296-4","display":"Kidney transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7104","display":"Bone Marrow Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28297-2","display":"Bone marrow transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-36/A0700","prefix":"A0700","text":"The patient should enter a \"+\" in the Medicaid Number section if their Medicaid application is pending, or \"N\" if they are not a recipient of Medicaid.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"The discharge goal for the patient pertains to their ability to transfer to and from a bed to a chair, which could also include a wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"The discharge goal for the patient is the ability to transition from lying on their back to sitting on the side of the bed without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Please code the patient's or resident's need for assistance with walking from room to room, with or without a device such as a cane, crutch, or walker, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - a helper completed the activity for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-3/C1610D","prefix":"C1610D","text":"Was the patient's or resident's thinking disorganized or incoherent, characterized by rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switches from subject to subject?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"The discharge goal for the patient is to attain the ability to stand and walk at least 50 feet, making two turns once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"The sections of the form, including the signature and title sections, were completed by the patient on the date indicated in the \"Date Section Completed H\".","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Does the patient have the ability to walk at least 10 feet in a room, corridor, or similar space once they are standing? Select from the following options for their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Did the facility or setting contact a physician, or the physician's designee, by midnight of the next calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"The discharge goal for the patient pertains to their ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, which is referred to as \"sit to stand\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"The discharge goal for the patient includes their ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If they are managing an ostomy, this will also include wiping the opening, but not managing the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"The form is questioning the patient's ability, once seated in a wheelchair or scooter, to wheel at least 150 feet in a corridor or similar space. This is a discharge goal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-3/C1610C","prefix":"C1610C","text":"Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? The possible answers could be 'Yes', 'No', or 'Sometimes'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-15/O0150D","prefix":"O0150D","text":"Is there documentation of the reason or reasons in the patient's or resident's medical record that indicates why the patient or resident was deemed medically unready for SBT by the second day of their stay at the Long-Term Care Hospital?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0130D2","prefix":"GG0130D2","text":"The discharge goal for the patient is to have the ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-15/O0250C","prefix":"O0250C","text":"If the patient has not received the influenza vaccine, please state the reason. The options may include: a) allergic to the vaccine, b) vaccine not available, c) personal beliefs, or d) other reasons.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"{Patient/resident} not in facility during this year's influenza vaccination season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26745-2","display":"Patient not in this facility during this year's influenza vaccination season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Received outside of this facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA184-4","display":"Received outside of this facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Not eligible - medical contraindication"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11091-8","display":"Not eligible - medical contraindication"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Offered and declined"}},{"valueCoding":{"system":"http://loinc.org","code":"LA186-9","display":"Offered and declined"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Not offered"}},{"valueCoding":{"system":"http://loinc.org","code":"LA187-7","display":"Not offered"}},{"valueCoding":{"system":"http://del.cms.gov","code":"6","display":"Inability to obtain influenza vaccine due to a declared shortage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26746-0","display":"Inability to obtain influenza vaccine due to a declared shortage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"The question on the form refers to the patient or resident's eating abilities, specifically their ability to utilize appropriate utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is presented to them. This is evaluated based on their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-15/O0150E","prefix":"O0150E","text":"If the patient or resident was deemed medically ready for a Spontaneous Breathing Trial (SBT), was the SBT performed by the second day of their Long Term Care Hospital (LTCH) stay?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"The question on the form assesses the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. The label for this section is 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"The patient's admission performance is evaluated based on their ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If the patient is managing an ostomy, the evaluation includes their ability to wipe the opening but not manage the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"The discharge goal for the patient is to have the ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"The patient's oral hygiene refers to their ability to use suitable items to clean their teeth. If applicable, the patient's ability to handle dentures includes inserting and removing dentures from their mouth and managing denture soaking and rinsing with the use of equipment. The discharge goal needs to be determined.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-11/K0200B","prefix":"K0200B","text":"The patient's weight in pounds should be based on the most recent measure taken in the last specified number of days. The weight must be measured consistently, in accordance with the standard practice of the facility or setting, which may include measurements in the morning after voiding, before meals, with shoes off, etc.","type":"integer","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"The form inquires about the patient's admission performance concerning their ability to roll from lying on their back to their left and right side, and then return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"The patient's oral hygiene pertains to their ability to use suitable items to clean their teeth. If applicable, their use of dentures involves their ability to insert and remove dentures into and from the mouth, as well as manage denture soaking and rinsing with the use of equipment. This information was gathered from their performance upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Please indicate the devices and aids that the patient or resident had used prior to their current illness, exacerbation, or injury. Check all that apply.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]}],"_id":"guKqXt8MPAi6yeKix"} {"id":"pbupcoBuWyD8N7qtY","responseType":"QuestionnaireResponse","status":"draft","authored":"2024-04-27T18:36:21.698Z","item":[{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0800","prefix":"A0800","text":"What is the patient's gender?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Female"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}]},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1100B","prefix":"A1100B","text":"What is the patient's preferred language?","type":"text","repeats":false,"readOnly":false,"maxLength":15},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"The form for the patient asks for their suffix.","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"What is the patient's National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-3/C1610E1","prefix":"C1610E1","text":"The patient's alertness level is normal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the patient or resident use a wheelchair and/or scooter upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"How many Stage 1 pressure injuries does the patient have?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"The patient has a certain number of stage 4 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0200","prefix":"A0200","text":"The type of provider for the patient needs to be specified.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Long-Term Care Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28448-1","display":"Long-term care hospital "}}]},{"linkId":"Section-15/O0250B","prefix":"O0250B","text":"What is the date the patient received the influenza vaccine?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0100C","prefix":"A0100C","text":"The patient's State Medicaid Facility or Provider Number is required.","type":"text","repeats":false,"readOnly":false,"maxLength":15},{"linkId":"Section-9/I0050","prefix":"I0050","text":"Please indicate the primary medical condition category for the patient or resident.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Acute Onset Respiratory Condition (e.g., aspiration and specified bacterial pneumonias)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27513-3","display":"Acute onset respiratory condition (e.g., aspiration and specified bacterial pneumonias)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Chronic Respiratory Condition (e.g., chronic obstructive pulmonary disease)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27514-1","display":"Chronic respiratory condition (e.g., chronic obstructive pulmonary disease)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Acute Onset and Chronic Respiratory Conditions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27515-8","display":"Acute onset and chronic respiratory conditions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Chronic Cardiac Condition (e.g., heart failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27516-6","display":"Chronic cardiac condition (e.g., heart failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Other Medical Condition. If \"Other Medical Condition\", enter ICD code in the boxes."}},{"valueCoding":{"system":"http://loinc.org","code":"LA16346-1","display":"Other medical condition"}}]},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"The patient has a certain number of Stage 2 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0210","prefix":"A0210","text":"The assessment reference date refers to the patient's observation end date.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1400","prefix":"A1400","text":"The patient needs to provide their payer information by checking all the boxes that apply.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Medicare (traditional fee-for-service)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6259-1","display":"Medicare (traditional fee-for-service)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Medicare (managed care/Part C/Medicare Advantage)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27554-7","display":"Medicare (managed care/Part C/Medicare Advantage)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Medicaid (traditional fee-for-service)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6257-5","display":"Medicaid (traditional fee-for-service)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Medicaid (managed care)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27556-2","display":"Medicaid (managed care)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Workers' compensation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6452-2","display":"Workers' compensation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Title programs (e.g., Title III, V, or XX)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6398-7","display":"Title programs (e.g., Title III, V, or XX)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Other government (e.g., TRICARE, VA, etc.)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10049-7","display":"Other government (e.g., TRICARE, VA, etc.)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Private insurance/Medigap"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10061-2","display":"Private insurance/Medigap"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Private managed care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27561-2","display":"Private managed care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Self-pay"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6369-8","display":"Self-pay"}},{"valueCoding":{"system":"http://del.cms.gov","code":"K","display":"No payer source"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18995-3","display":"No payor source"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"Other"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}]},{"linkId":"Section-15/O0100","prefix":"O0100","text":"Please check all of the following special treatments, procedures, and programs that were performed on the patient.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Non-invasive Ventilator (BIPAP, CPAP)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27542-2","display":"Non-invasive ventilator (BIPAP, CPAP)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"IV Medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27972-1","display":"IV medications, (if checked, please specify below)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H2a","display":"Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28269-1","display":"Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Dialysis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA7216-0","display":"Dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-36/A0250","prefix":"A0250","text":"What is the reason for the patient's assessment?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Admission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10922-5","display":"Admission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Planned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18067-1","display":"Planned discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"12","display":"Expired"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10325-1","display":"Expired"}}]},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record for the patient needs to be identified.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Add new assessment/record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27573-7","display":"Add new assessment/record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Modify existing record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12664-1","display":"Modify existing record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Inactivate existing record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12665-8","display":"Inactivate existing record"}}]},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"The sections were completed and dated by the patient, who then signed and titled the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"The patient has a certain number of unstageable pressure injuries that are presenting as deep tissue injury.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Where was the patient immediately preceding this admission? Was the patient admitted from home, another healthcare facility, or somewhere else?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11501-6","display":"Community residential setting (e.g., private home, assisted living, group home, adult foster care)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Long-term care facility (LTC)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18066-3","display":"Long-term care facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Hospital emergency department"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11504-0","display":"Hospital emergency department"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Short-stay acute hospital (IPPS)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10078-6","display":"Short-stay acute hospital (IPPS)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"Inpatient rehabilitation facility or unit (IRF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27548-9","display":"Inpatient rehabilitation facility or unit (IRF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"Psychiatric hospital or unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10065-3","display":"Psychiatric hospital or unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Intellectually Disabled/Developmentally Disabled (ID/DD) facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28224-6","display":"Intellectually disabled/developmentally disabled (ID/DD) facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Hospice"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6216-1","display":"Hospice"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-15/O0250A","prefix":"O0250A","text":"Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"The patient must provide their signature, title, and the date on which they completed Section I of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"The patient needs to provide their Signature, Title, and the Date they completed Section D.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-2/B0100","prefix":"B0100","text":"The patient is in a comatose state with no discernible consciousness, persisting in a vegetative state.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Please select the one category that best describes the patient's bladder continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}]},{"linkId":"Section-3/C1610A","prefix":"C1610A","text":"Is there evidence of an acute change in the patient's or resident's mental status from their baseline?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Did a complete drug regimen review for the patient identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}]},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Does the patient understand both verbal and non-verbal content with the use of their hearing aid or device, excluding any language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}]},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Does the patient express their ideas and wants, considering both verbal and non-verbal expression and excluding language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}]},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"The discharge goal for the patient is to have the ability to get on and off a toilet or commode independently.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"The form asks about the patient's admission performance regarding their ability to transfer to and from a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-36/A1200","prefix":"A1200","text":"What is the patient's marital status? Is the patient single, married, divorced, separated, or widowed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Divorced"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}]},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"The discharge goal for the patient is to have the ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0500B","prefix":"Z0500B","text":"The date on which the Registered Nurse Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-15/O0150B","prefix":"O0150B","text":"The patient was assessed for readiness for spontaneous breathing trial (SBT) by the second day of their Long Term Care Hospital (LTCH) stay.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Does this patient or resident have one or more unhealed pressure ulcers or injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"The signature, title, and date of the section completed F were filled out by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-36/A1100A","prefix":"A1100A","text":"Does the patient need or want an interpreter to communicate with a doctor or health care staff? Please indicate 'yes' or 'no'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Unable to determine"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11137-9","display":"Unable to determine"}}]},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"The patient completed section B and then they signed and dated the form, also providing their title.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-15/O0150A","prefix":"O0150A","text":"Was the patient on invasive mechanical ventilator support upon admission to the Long-Term Care Hospital?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No, not on invasive mechanical ventilation support upon admission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28329-3","display":"No, not on invasive mechanical ventilation support"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, weaning"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28330-1","display":"Yes, weaning"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, non-weaning"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28331-9","display":"Yes, non-weaning"}}]},{"linkId":"Section-9/I0050A","prefix":"I0050A","text":"If the patient has an \"Other Medical Condition\", they should enter the ICD code in the provided boxes.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"How many unstageable pressure ulcers does the patient have due to the coverage of the wound bed by slough and/or eschar?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"The patient's signature, title, and the date are required in the completed Section G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"The form requires the patient's signature, title, the sections they completed, and the date on which Section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-11/K0200A","prefix":"K0200A","text":"Please record the most recent measurement of the patient's height in inches since their admission.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"The admission date of the patient is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-19/Z0500A","prefix":"Z0500A","text":"The form requires the patient's signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Please select the one category that best describes the patient's or resident's bowel continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}]},{"linkId":"Section-36/A1000","prefix":"A1000","text":"The patient should check all the applicable options for their race or ethnicity.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}]},{"linkId":"Section-3/C1610B","prefix":"C1610B","text":"Did the patient's abnormal behavior fluctuate during the day, that is, did it tend to come and go or increase and decrease in severity?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title in the designated sections and also indicate the date when each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"The form asks if, once standing, the patient has the ability to walk at least 50 feet and make two turns for their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"How many Stage 3 pressure ulcers does the patient have?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"The form asks about the patient's admission performance regarding their ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"The form asks about the patient's admission performance in regards to their ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"The discharge goal for the patient is to gain the ability to stand up and walk at least 10 feet in a room, corridor, or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"The form asks about the patient's admission performance in terms of their ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-3/C1610E2","prefix":"C1610E2","text":"Is the patient vigilant (hyperalert), lethargic (drowsy, easily aroused), in a stupor (difficult to arouse), or in a coma (unarousable)?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature and title, and complete the relevant sections. The date when the section was completed is also required.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"The discharge goal for the patient is to achieve the ability to walk at least 150 feet in a corridor or similar space, once they are able to stand.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"The patient must provide their signature and title, as well as complete the sections indicated. The date when the section was completed has to be marked as 'A'.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0130D1","prefix":"GG0130D1","text":"The admission performance form inquires about the patient's ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"The form asks about the patient's admission performance, specifically inquiring about their ability to stand and walk at least 150 feet in a corridor or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"The discharge goal for the patient or resident is to gain the ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"The discharge goal for the patient is to once be seated in a wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"The form asks about the patient's admission performance, specifically whether, once seated in a wheelchair or scooter, they are able to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"The section labeled \"Signature, Title, Sections, Date Section Completed L\" on the patient's form needs to be filled out.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"How many unstageable pressure ulcers or injuries does the patient have due to a non-removable dressing or device?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-15/O0150C","prefix":"O0150C","text":"The patient was deemed medically ready for Spontaneous Breathing Trial (SBT) by day 2 of their Long Term Care Hospital (LTCH) stay.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"The form asks about the patient's admission performance in relation to their ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-9/I0000","prefix":"I0000","text":"Has the patient had any active diagnoses in the last 7 days? Please check all that apply. The diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0103","display":"Metastatic Cancer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28289-9","display":"Metastatic cancer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0104","display":"Severe Cancer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28290-7","display":"Severe cancer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0605","display":"Severe Left Systolic/Ventricular Dysfunction (known ejection fraction <= 30%)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28298-0","display":"Severe left systolic/ventricular dysfunction (known ejection fraction <= 30%)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1501","display":"Chronic Kidney Disease, Stage 5"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27518-2","display":"Chronic kidney disease, stage 5"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1502","display":"Acute Renal Failure"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27519-0","display":"Acute renal failure"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2101","display":"Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27520-8","display":"Septicemia, sepsis, systemic inflammatory response syndrome/shock"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2600","display":"Central Nervous System Infections, Opportunistic Infections, Bone/Joint/Muscle Infections/Necrosis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27521-6","display":"Central nervous system infections, opportunistic infections, bone/joint/muscle infections/necrosis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27539-8","display":"Diabetes mellitus (DM)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4100","display":"Major Lower Limb Amputation (e.g., above knee, below knee)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27522-4","display":"Major lower limb amputation (e.g., above knee, below knee)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4501","display":"Stroke"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22099-8","display":"Stroke"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4801","display":"Dementia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA20372-1","display":"Dementia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4900","display":"Hemiplegia or Hemiparesis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27523-2","display":"Hemiplegia or hemiparesis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5000","display":"Paraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA25276-9","display":"Paraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5101","display":"Complete Tetraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27528-1","display":"Complete tetraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5102","display":"Incomplete Tetraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27529-9","display":"Incomplete tetraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5110","display":"Other Spinal Cord Disorder/Injury (e.g., myelitis, cauda equina syndrome)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27530-7","display":"Other spinal cord disorder/injury (e.g., myelitis, cauda equina syndrome)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5200","display":"Multiple Sclerosis (MS)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27531-5","display":"Multiple sclerosis (MS)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5250","display":"Huntington's Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27532-3","display":"Huntington's disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5300","display":"Parkinson's Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27533-1","display":"Parkinson's disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5450","display":"Amyotrophic Lateral Sclerosis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27534-9","display":"Amyotrophic lateral sclerosis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5455","display":"Other Progressive Neuromuscular Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28291-5","display":"Other progressive neuromuscular disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5460","display":"Locked-In State"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27535-6","display":"Locked-in state"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5470","display":"Severe Anoxic Brain Damage, Cerebral Edema, or Compression of Brain"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27536-4","display":"Severe anoxic brain damage, cerebral edema, or compression of brain"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5480","display":"Other Severe Neurological Injury, Disease, or Dysfunction"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28292-3","display":"Other severe neurological injury, disease, or dysfunction"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5601","display":"Malnutrition (protein or calorie)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27537-2","display":"Malnutrition (protein or calorie)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5602","display":"At Risk for Malnutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27538-0","display":"At risk for malnutrition"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7100","display":"Lung Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28293-1","display":"Lung transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7101","display":"Heart Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28294-9","display":"Heart transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7102","display":"Liver Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28295-6","display":"Liver transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7103","display":"Kidney Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28296-4","display":"Kidney transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7104","display":"Bone Marrow Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28297-2","display":"Bone marrow transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-36/A0700","prefix":"A0700","text":"The patient should enter a \"+\" in the Medicaid Number section if their Medicaid application is pending, or \"N\" if they are not a recipient of Medicaid.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"The discharge goal for the patient pertains to their ability to transfer to and from a bed to a chair, which could also include a wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"The discharge goal for the patient is the ability to transition from lying on their back to sitting on the side of the bed without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Please code the patient's or resident's need for assistance with walking from room to room, with or without a device such as a cane, crutch, or walker, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - a helper completed the activity for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-3/C1610D","prefix":"C1610D","text":"Was the patient's or resident's thinking disorganized or incoherent, characterized by rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switches from subject to subject?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"The discharge goal for the patient is to attain the ability to stand and walk at least 50 feet, making two turns once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"The sections of the form, including the signature and title sections, were completed by the patient on the date indicated in the \"Date Section Completed H\".","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Does the patient have the ability to walk at least 10 feet in a room, corridor, or similar space once they are standing? Select from the following options for their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Did the facility or setting contact a physician, or the physician's designee, by midnight of the next calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"The discharge goal for the patient pertains to their ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, which is referred to as \"sit to stand\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"The discharge goal for the patient includes their ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If they are managing an ostomy, this will also include wiping the opening, but not managing the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"The form is questioning the patient's ability, once seated in a wheelchair or scooter, to wheel at least 150 feet in a corridor or similar space. This is a discharge goal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-3/C1610C","prefix":"C1610C","text":"Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? The possible answers could be 'Yes', 'No', or 'Sometimes'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-15/O0150D","prefix":"O0150D","text":"Is there documentation of the reason or reasons in the patient's or resident's medical record that indicates why the patient or resident was deemed medically unready for SBT by the second day of their stay at the Long-Term Care Hospital?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0130D2","prefix":"GG0130D2","text":"The discharge goal for the patient is to have the ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-15/O0250C","prefix":"O0250C","text":"If the patient has not received the influenza vaccine, please state the reason. The options may include: a) allergic to the vaccine, b) vaccine not available, c) personal beliefs, or d) other reasons.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"{Patient/resident} not in facility during this year's influenza vaccination season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26745-2","display":"Patient not in this facility during this year's influenza vaccination season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Received outside of this facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA184-4","display":"Received outside of this facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Not eligible - medical contraindication"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11091-8","display":"Not eligible - medical contraindication"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Offered and declined"}},{"valueCoding":{"system":"http://loinc.org","code":"LA186-9","display":"Offered and declined"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Not offered"}},{"valueCoding":{"system":"http://loinc.org","code":"LA187-7","display":"Not offered"}},{"valueCoding":{"system":"http://del.cms.gov","code":"6","display":"Inability to obtain influenza vaccine due to a declared shortage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26746-0","display":"Inability to obtain influenza vaccine due to a declared shortage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"The question on the form refers to the patient or resident's eating abilities, specifically their ability to utilize appropriate utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is presented to them. This is evaluated based on their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-15/O0150E","prefix":"O0150E","text":"If the patient or resident was deemed medically ready for a Spontaneous Breathing Trial (SBT), was the SBT performed by the second day of their Long Term Care Hospital (LTCH) stay?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"The question on the form assesses the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. The label for this section is 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"The patient's admission performance is evaluated based on their ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If the patient is managing an ostomy, the evaluation includes their ability to wipe the opening but not manage the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"The discharge goal for the patient is to have the ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"The patient's oral hygiene refers to their ability to use suitable items to clean their teeth. If applicable, the patient's ability to handle dentures includes inserting and removing dentures from their mouth and managing denture soaking and rinsing with the use of equipment. The discharge goal needs to be determined.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-11/K0200B","prefix":"K0200B","text":"The patient's weight in pounds should be based on the most recent measure taken in the last specified number of days. The weight must be measured consistently, in accordance with the standard practice of the facility or setting, which may include measurements in the morning after voiding, before meals, with shoes off, etc.","type":"integer","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"The form inquires about the patient's admission performance concerning their ability to roll from lying on their back to their left and right side, and then return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"The patient's oral hygiene pertains to their ability to use suitable items to clean their teeth. If applicable, their use of dentures involves their ability to insert and remove dentures into and from the mouth, as well as manage denture soaking and rinsing with the use of equipment. This information was gathered from their performance upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Please indicate the devices and aids that the patient or resident had used prior to their current illness, exacerbation, or injury. Check all that apply.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]}],"_id":"mx922AbXv9fvH7CuA"} {"responseType":"QuestionnaireResponse","id":"OASIS-DAH-D1-012020","questionnaire":"OASIS-DAH-D1-012020","title":"Outcome and Assessment Information Set - Death at Home","description":"Data set for use in home health agencies (HHAs), State agencies, software vendors, professional associations and other Federal agencies in implementing and maintaining OASIS.","status":"draft","authored":"2024-04-27T18:41:02.853Z","item":[{"linkId":"Section-21/M0080","prefix":"M0080","text":"The discipline of the person who is completing the assessment for the patient is required.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"RN"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"PT"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"SLP/ST"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"OT"}}]},{"linkId":"Section-21/M0090","prefix":"M0090","text":"The date the assessment was completed for the patient.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-21/M0100_","prefix":"M0100_","text":"This assessment is currently being completed for the following reason pertaining to the patient.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA6390-4","display":"Start of care - further visits planned"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6366-4","display":"Resumption of care (after inpatient stay)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6355-7","display":"Recertification (follow-up) reassessment"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6312-8","display":"Other follow-up"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6402-7","display":"Transferred to an inpatient facility - patient not discharged from agency"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6401-9","display":"Transferred to an inpatient facility - patient discharged from agency"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6179-1","display":"Death at home"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6184-1","display":"Discharge from agency"}}]},{"linkId":"Section-20/A0100A","prefix":"A0100A","text":"Does the patient have a National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-20/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-20/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0700","prefix":"A0700","text":"The patient's Medicaid number should be entered in the provided space. If the Medicaid application is pending, enter \"+\". If the patient is not a Medicaid recipient, enter \"N\".","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-20/A0800","prefix":"A0800","text":"What is the patient's gender? The possible answers are male, female, or prefer not to say.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}]},{"linkId":"Section-20/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0014","prefix":"M0014","text":"In which state does the patient currently reside?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-20/M0016","prefix":"M0016","text":"What is the patient's Branch ID Number?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-20/M0020","prefix":"M0020","text":"What is the patient's or resident's ID number?","type":"text","repeats":false,"readOnly":false,"maxLength":20},{"linkId":"Section-20/M0030","prefix":"M0030","text":"What is the start of care date for the patient?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0032","prefix":"M0032","text":"The date of the patient's resumption of care is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0050","prefix":"M0050","text":"What is the patient's state of residence?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-20/A0550","prefix":"A0550","text":"What is the patient's or resident's ZIP code?","type":"text","repeats":false,"readOnly":false,"maxLength":11},{"linkId":"Section-20/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-20/A0500C","prefix":"A0500C","text":"The patient's last name is required.","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-20/A0500D","prefix":"A0500D","text":"What is the patient's suffix?","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-35/M0906","prefix":"M0906","text":"The form asks for the date of the patient's or resident's discharge, transfer, or death at home to be entered in the \"Discharge/Transfer/Death Date\" field.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-31/N2005","prefix":"N2005","text":"Did the facility or setting contact and complete the actions prescribed or recommended by the physician, or the physician's designee, by midnight of the next calendar day each time potential clinically significant medication issues were identified for the patient since their admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27681-8","display":"NA-There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications"}}]},null,{"linkId":"Section-10/J1900A","prefix":"J1900A","text":"The patient exhibits no injury - there is no evidence of any injury noted on the physical assessment performed by the nurse or primary care clinician; the patient has made no complaints of pain or injury; moreover, there has been no change in the patient's behavior after the fall.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]},{"linkId":"Section-10/J1900B","prefix":"J1900B","text":"The form asks whether the patient has any minor injuries, including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains, or any fall-related injury that has caused them to complain of pain.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]},{"linkId":"Section-10/J1900C","prefix":"J1900C","text":"Has the patient had any major injuries such as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]}],"_id":"2r68orMuvgs9jogiq"} {"responseType":"QuestionnaireResponse","id":"OASIS-DAH-D1-012020","questionnaire":"OASIS-DAH-D1-012020","title":"Outcome and Assessment Information Set - Death at Home","description":"Data set for use in home health agencies (HHAs), State agencies, software vendors, professional associations and other Federal agencies in implementing and maintaining OASIS.","status":"draft","authored":"2024-04-27T18:41:02.853Z","item":[{"linkId":"Section-21/M0080","prefix":"M0080","text":"The discipline of the person who is completing the assessment for the patient is required.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"RN"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"PT"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"SLP/ST"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"OT"}}]},{"linkId":"Section-21/M0090","prefix":"M0090","text":"The date the assessment was completed for the patient.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-21/M0100_","prefix":"M0100_","text":"This assessment is currently being completed for the following reason pertaining to the patient.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA6390-4","display":"Start of care - further visits planned"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6366-4","display":"Resumption of care (after inpatient stay)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6355-7","display":"Recertification (follow-up) reassessment"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6312-8","display":"Other follow-up"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6402-7","display":"Transferred to an inpatient facility - patient not discharged from agency"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6401-9","display":"Transferred to an inpatient facility - patient discharged from agency"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6179-1","display":"Death at home"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6184-1","display":"Discharge from agency"}}]},{"linkId":"Section-20/A0100A","prefix":"A0100A","text":"Does the patient have a National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-20/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-20/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0700","prefix":"A0700","text":"The patient's Medicaid number should be entered in the provided space. If the Medicaid application is pending, enter \"+\". If the patient is not a Medicaid recipient, enter \"N\".","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-20/A0800","prefix":"A0800","text":"What is the patient's gender? The possible answers are male, female, or prefer not to say.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}]},{"linkId":"Section-20/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0014","prefix":"M0014","text":"In which state does the patient currently reside?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-20/M0016","prefix":"M0016","text":"What is the patient's Branch ID Number?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-20/M0020","prefix":"M0020","text":"What is the patient's or resident's ID number?","type":"text","repeats":false,"readOnly":false,"maxLength":20},{"linkId":"Section-20/M0030","prefix":"M0030","text":"What is the start of care date for the patient?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0032","prefix":"M0032","text":"The date of the patient's resumption of care is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0050","prefix":"M0050","text":"What is the patient's state of residence?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-20/A0550","prefix":"A0550","text":"What is the patient's or resident's ZIP code?","type":"text","repeats":false,"readOnly":false,"maxLength":11},{"linkId":"Section-20/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-20/A0500C","prefix":"A0500C","text":"The patient's last name is required.","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-20/A0500D","prefix":"A0500D","text":"What is the patient's suffix?","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-35/M0906","prefix":"M0906","text":"The form asks for the date of the patient's or resident's discharge, transfer, or death at home to be entered in the \"Discharge/Transfer/Death Date\" field.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-31/N2005","prefix":"N2005","text":"Did the facility or setting contact and complete the actions prescribed or recommended by the physician, or the physician's designee, by midnight of the next calendar day each time potential clinically significant medication issues were identified for the patient since their admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27681-8","display":"NA-There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications"}}]},null,{"linkId":"Section-10/J1900A","prefix":"J1900A","text":"The patient exhibits no injury - there is no evidence of any injury noted on the physical assessment performed by the nurse or primary care clinician; the patient has made no complaints of pain or injury; moreover, there has been no change in the patient's behavior after the fall.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]},{"linkId":"Section-10/J1900B","prefix":"J1900B","text":"The form asks whether the patient has any minor injuries, including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains, or any fall-related injury that has caused them to complain of pain.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]},{"linkId":"Section-10/J1900C","prefix":"J1900C","text":"Has the patient had any major injuries such as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]}],"_id":"ThZYx2SZxmNMn2SFJ"} {"responseType":"QuestionnaireResponse","id":"OASIS-DAH-D1-012020","questionnaire":"OASIS-DAH-D1-012020","title":"Outcome and Assessment Information Set - Death at Home","description":"Data set for use in home health agencies (HHAs), State agencies, software vendors, professional associations and other Federal agencies in implementing and maintaining OASIS.","status":"draft","authored":"2024-04-27T18:41:02.853Z","item":[{"linkId":"Section-21/M0080","prefix":"M0080","text":"The discipline of the person who is completing the assessment for the patient is required.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"RN"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"PT"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"SLP/ST"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"OT"}}]},{"linkId":"Section-21/M0090","prefix":"M0090","text":"The date the assessment was completed for the patient.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-21/M0100_","prefix":"M0100_","text":"This assessment is currently being completed for the following reason pertaining to the patient.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA6390-4","display":"Start of care - further visits planned"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6366-4","display":"Resumption of care (after inpatient stay)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6355-7","display":"Recertification (follow-up) reassessment"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6312-8","display":"Other follow-up"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6402-7","display":"Transferred to an inpatient facility - patient not discharged from agency"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6401-9","display":"Transferred to an inpatient facility - patient discharged from agency"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6179-1","display":"Death at home"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6184-1","display":"Discharge from agency"}}]},{"linkId":"Section-20/A0100A","prefix":"A0100A","text":"Does the patient have a National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-20/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-20/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0700","prefix":"A0700","text":"The patient's Medicaid number should be entered in the provided space. If the Medicaid application is pending, enter \"+\". If the patient is not a Medicaid recipient, enter \"N\".","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-20/A0800","prefix":"A0800","text":"What is the patient's gender? The possible answers are male, female, or prefer not to say.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}]},{"linkId":"Section-20/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0014","prefix":"M0014","text":"In which state does the patient currently reside?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-20/M0016","prefix":"M0016","text":"What is the patient's Branch ID Number?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-20/M0020","prefix":"M0020","text":"What is the patient's or resident's ID number?","type":"text","repeats":false,"readOnly":false,"maxLength":20},{"linkId":"Section-20/M0030","prefix":"M0030","text":"What is the start of care date for the patient?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0032","prefix":"M0032","text":"The date of the patient's resumption of care is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0050","prefix":"M0050","text":"What is the patient's state of residence?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-20/A0550","prefix":"A0550","text":"What is the patient's or resident's ZIP code?","type":"text","repeats":false,"readOnly":false,"maxLength":11},{"linkId":"Section-20/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-20/A0500C","prefix":"A0500C","text":"The patient's last name is required.","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-20/A0500D","prefix":"A0500D","text":"What is the patient's suffix?","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-35/M0906","prefix":"M0906","text":"The form asks for the date of the patient's or resident's discharge, transfer, or death at home to be entered in the \"Discharge/Transfer/Death Date\" field.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-31/N2005","prefix":"N2005","text":"Did the facility or setting contact and complete the actions prescribed or recommended by the physician, or the physician's designee, by midnight of the next calendar day each time potential clinically significant medication issues were identified for the patient since their admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27681-8","display":"NA-There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications"}}]},null,{"linkId":"Section-10/J1900A","prefix":"J1900A","text":"The patient exhibits no injury - there is no evidence of any injury noted on the physical assessment performed by the nurse or primary care clinician; the patient has made no complaints of pain or injury; moreover, there has been no change in the patient's behavior after the fall.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]},{"linkId":"Section-10/J1900B","prefix":"J1900B","text":"The form asks whether the patient has any minor injuries, including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains, or any fall-related injury that has caused them to complain of pain.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]},{"linkId":"Section-10/J1900C","prefix":"J1900C","text":"Has the patient had any major injuries such as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]}],"_id":"onkRDHixbBhDPZqPo"} {"responseType":"QuestionnaireResponse","questionnaire":"HIS-HA-2.00.0","id":"HIS-HA-2.00.0-1","title":"Hospice Item Set - Hospice Admission Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-09-20T06:29:57.933Z","item":[{"linkId":"Section-36","text":"Section A: Administrative Information","type":"group","readOnly":true,"item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0"},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3"},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5"},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Admitted From. Immediately preceding this admission, where was the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.6"},{"linkId":"Section-36/A0550","prefix":"A0550","text":"{Patient/Resident} ZIP Code.","type":"text","repeats":false,"readOnly":false,"maxLength":11,"id":"item.0.item.7"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1"}],"id":"item.0.item.8"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3"}],"id":"item.0.item.9"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1"}],"id":"item.0.item.10"},{"linkId":"Section-36/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.11"},{"linkId":"Section-36/A1400","prefix":"A1400","text":"Payer Information: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.12"},{"linkId":"Section-36/A0205","prefix":"A0205","text":"Site of Service at Admission","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.13"},{"linkId":"Section-36/A0245","prefix":"A0245","text":"Date Initial Nursing Assessment Initiated","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.14"}],"id":"item.0","description":"The patient must fill out Section A, which pertains to administrative information."},{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0","description":"The form asks the patient to enter their Medicaid number. If their Medicaid is still pending, they should enter \"+\". If they are not a Medicaid recipient, they should enter \"N\"."},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1","description":"What is the patient's gender? The options are male, female, or prefer not to say."},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2","description":"What is the patient's date of birth?"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3","description":"The type of record for the patient needs to be identified."},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4","description":"What is the reason for the patient's assessment?"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5","description":"What is the patient's admission date?"},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Admitted From. Immediately preceding this admission, where was the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.6","description":"Where was the patient immediately preceding this admission? Was the patient admitted from their home, another hospital, a nursing home, or somewhere else?"},{"linkId":"Section-36/A0550","prefix":"A0550","text":"{Patient/Resident} ZIP Code.","type":"text","repeats":false,"readOnly":false,"maxLength":11,"id":"item.0.item.7","description":"What is the patient's or resident's ZIP code?"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1"}],"id":"item.0.item.8","description":"The patient needs to provide the numbers associated with their facility provider."},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0","description":"What is the patient's National Provider Identifier (NPI)?"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1","description":"What is the patient's CMS Certification Number (CCN)?"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3"}],"id":"item.0.item.9","description":"What is the legal name of the patient or resident?"},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0","description":"What is the patient's first name?"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1","description":"What is the patient's middle initial?"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2","description":"What is the patient's last name?"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3","description":"What is the patient's suffix?"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1"}],"id":"item.0.item.10","description":"The form requests the patient's Social Security and Medicare numbers."},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0","description":"What is the patient's Social Security Number?"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1","description":"What is the patient's Medicare number?"},{"linkId":"Section-36/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.11","description":"The patient must check all the boxes that apply to their race or ethnicity."},{"linkId":"Section-36/A1400","prefix":"A1400","text":"Payer Information: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.12","description":"The patient should provide all applicable payer information by checking all the relevant options."},{"linkId":"Section-36/A0205","prefix":"A0205","text":"Site of Service at Admission","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.13","description":"What was the patient's site of service at the time of admission?"},{"linkId":"Section-36/A0245","prefix":"A0245","text":"Date Initial Nursing Assessment Initiated","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.14","description":"The date the initial nursing assessment for the patient was initiated."},{"linkId":"Section-47","text":"Section F: Preferences","type":"group","readOnly":true,"item":[{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0"},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1"}],"id":"item.1.item.0"},{"linkId":"Section-47/F2100","prefix":"F2100","text":"Other Life-Sustaining Treatment Preferences","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0"},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1"}],"id":"item.1.item.1"},{"linkId":"Section-47/F2200","prefix":"F2200","text":"Hospitalization Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0"},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1"}],"id":"item.1.item.2"},{"linkId":"Section-47/F3000","prefix":"F3000","text":"Spiritual/Existential Concerns","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0"},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1"}],"id":"item.1.item.3"}],"id":"item.1","description":"In section F of the form, the patient's preferences are discussed."},{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0"},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1"}],"id":"item.1.item.0","description":"Does the patient have a preference regarding CPR?"},{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0","description":"Was the patient, or the responsible party, asked about their preference regarding the use of cardiopulmonary resuscitation (CPR)? Please select the most accurate response."},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1","description":"The date when the patient or responsible party was first asked about their preference regarding the use of CPR."},{"linkId":"Section-47/F2100","prefix":"F2100","text":"Other Life-Sustaining Treatment Preferences","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0"},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1"}],"id":"item.1.item.1","description":"Does the patient have other life-sustaining treatment preferences?"},{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0","description":"Was the patient or responsible party asked about their preferences regarding life-sustaining treatments other than CPR? Please select the most accurate response."},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1","description":"The date on which the patient or responsible party was first asked about their preferences regarding life-sustaining treatments other than Cardiopulmonary Resuscitation was:"},{"linkId":"Section-47/F2200","prefix":"F2200","text":"Hospitalization Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0"},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1"}],"id":"item.1.item.2","description":"The patient has to choose their hospitalization preference."},{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0","description":"Was the patient or the responsible party asked about their preference regarding hospitalization? Please select the most accurate response."},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1","description":"The date that the patient, resident, or responsible party was first asked about their preference regarding hospitalization was:"},{"linkId":"Section-47/F3000","prefix":"F3000","text":"Spiritual/Existential Concerns","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0"},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1"}],"id":"item.1.item.3","description":"Does the patient have any spiritual or existential concerns?"},{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0","description":"Was the patient or resident and/or their caregiver asked about any spiritual or existential concerns? Please select the most accurate response."},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1","description":"When was the patient or their caregiver first asked about their spiritual or existential concerns?"},{"linkId":"Section-9","text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal Diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"}],"id":"item.2","description":"In Section I of the form, the patient's active diagnoses are listed."},{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal Diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"What is the patient's principal diagnosis?"},{"linkId":"Section-10","text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J0900","prefix":"J0900","text":"Pain Screening","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3"}],"id":"item.3.item.0"},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Pain Active Problem. Is pain an active problem for the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.1"},{"linkId":"Section-10/J0910","prefix":"J0910","text":"Comprehensive Pain Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2"}],"id":"item.3.item.2"},{"linkId":"Section-10/J2030","prefix":"J2030","text":"Screening for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2"}],"id":"item.3.item.3"},{"linkId":"Section-10/J2040","prefix":"J2040","text":"Treatment for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0"},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2"}],"id":"item.3.item.4"}],"id":"item.3","description":"In Section J of the form, the patient is asked about their health conditions."},{"linkId":"Section-10/J0900","prefix":"J0900","text":"Pain Screening","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3"}],"id":"item.3.item.0","description":"The patient is asked to participate in a pain screening."},{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0","description":"Was the patient or resident screened for pain?"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1","description":"When was the patient first screened for pain?"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2","description":"The severity of the patient's or resident's pain was:"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3","description":"The type of standardized pain tool used for the patient is:"},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Pain Active Problem. Is pain an active problem for the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.1","description":"Is pain an active problem for the patient or resident?"},{"linkId":"Section-10/J0910","prefix":"J0910","text":"Comprehensive Pain Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2"}],"id":"item.3.item.2","description":"The patient is required to fill out a comprehensive pain assessment."},{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0","description":"Was a comprehensive pain assessment conducted on the patient?"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1","description":"When was the date of the patient's comprehensive pain assessment?"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2","description":"The patient's form included a comprehensive pain assessment which stated: \"Check all that apply.\""},{"linkId":"Section-10/J2030","prefix":"J2030","text":"Screening for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2"}],"id":"item.3.item.3","description":"The patient is undergoing screening for shortness of breath."},{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0","description":"Was the patient or resident screened for symptoms of shortness of breath?"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1","description":"What was the date of the patient's first screening for shortness of breath?"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2","description":"Did the screening indicate that the patient had shortness of breath?"},{"linkId":"Section-10/J2040","prefix":"J2040","text":"Treatment for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0"},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2"}],"id":"item.3.item.4","description":"What is the patient's treatment for shortness of breath?"},{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0","description":"Was the treatment for the patient's shortness of breath initiated? Please select the most accurate response."},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1","description":"What is the date when the treatment for shortness of breath was initiated for the patient?"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2","description":"What types of treatment for shortness of breath has the patient initiated? Please check all that apply."},{"linkId":"Section-14","text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/N0500","prefix":"N0500","text":"Scheduled Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1"}],"id":"item.4.item.0"},{"linkId":"Section-14/N0510","prefix":"N0510","text":"PRN Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0"},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1"}],"id":"item.4.item.1"},{"linkId":"Section-14/N0520","prefix":"N0520","text":"Bowel Regimen - Complete only if {scheduled opioid or PRN opioid = yes}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0"},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1"}],"id":"item.4.item.2"}],"id":"item.4","description":"In Section N of the form, the patient is asked to provide information about their medications."},{"linkId":"Section-14/N0500","prefix":"N0500","text":"Scheduled Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1"}],"id":"item.4.item.0","description":"Does the patient have a scheduled opioid medication regimen?"},{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0","description":"Did the patient have a scheduled opioid initiated or continued?"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1","description":"The date the patient's opioid treatment was initiated or continued is scheduled for:"},{"linkId":"Section-14/N0510","prefix":"N0510","text":"PRN Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0"},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1"}],"id":"item.4.item.1","description":"Does the patient take opioid medication as needed?"},{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0","description":"Was a PRN opioid initiated or continued for the patient? The answer choices are: initiated, continued, or neither."},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1","description":"The date on which the patient's PRN opioid was initiated or continued."},{"linkId":"Section-14/N0520","prefix":"N0520","text":"Bowel Regimen - Complete only if {scheduled opioid or PRN opioid = yes}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0"},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1"}],"id":"item.4.item.2","description":"The patient should complete the section \"Bowel Regimen\" only if they are scheduled for opioid treatment or have been prescribed opioids on an as-needed basis."},{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0","description":"Was a bowel regimen initiated or continued for the patient? Please select the most accurate response."},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1","description":"The date when the patient's bowel regimen was initiated or continued is required."},{"linkId":"Section-50","text":"Section O: Service Utilization","type":"group","readOnly":true,"item":[{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.0"}],"id":"item.5","description":"In Section O of the form, the patient's service utilization is assessed."},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.0","description":"What was the level of care the patient received in the final 3 days?"},{"linkId":"Section-48","text":"Section Z: Record Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0"},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1"}],"id":"item.6","description":"In section Z of the form, the administration records pertaining to the patient are documented."},{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0","description":"The signature of the person who completed the patient's assessment is required."},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0","description":"The patient is required to provide their signature, title, and date they completed section A."},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1","description":"The patient needs to provide their Signature, Title, ensure all Sections are filled out, and include the Date the Section was completed B."},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2","description":"The patient needs to provide their signature, title, and complete the sections required on the form. They should also include the date the section was completed, indicated as section C."},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3","description":"The patient filled out the signature, title, and sections, and completed section D on a specific date."},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4","description":"The sections of the form labeled \"Signature\", \"Title\", and \"Date Section Completed E\" should be filled out by the patient."},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5","description":"The form for the patient includes sections for signature, title, and the date when the section was completed."},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6","description":"The patient's signature, title, and the date the section was completed are all required in Section G."},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7","description":"The patient is required to provide their signature and title in the designated sections, and also specify the date when the section was completed."},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8","description":"The patient needs to provide their signature, title, and the sections they have completed on the form, along with the date the section was finished."},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9","description":"The patient is required to provide their signature, title, and date for each completed section on the form."},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10","description":"The patient is required to provide their signature, title, and date on the sections they have completed in Section K."},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11","description":"The patient must provide their signature, title, and date in the sections indicated upon completion."},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1","description":"The signature of the RN Coordinator is required to verify the completion of the patient's assessment."},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0","description":"The form requires the patient's signature."},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1","description":"The date on which the Registered Nurse Assessment Coordinator signed the patient's assessment as complete."},null],"_id":"yAofoXWeYrpdEoNkY"} {"responseType":"QuestionnaireResponse","questionnaire":"HIS-HA-2.00.0","id":"HIS-HA-2.00.0-1","title":"Hospice Item Set - Hospice Admission Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-09-20T06:29:57.933Z","item":[{"linkId":"Section-36","text":"Section A: Administrative Information","type":"group","readOnly":true,"item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0"},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3"},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5"},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Admitted From. Immediately preceding this admission, where was the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.6"},{"linkId":"Section-36/A0550","prefix":"A0550","text":"{Patient/Resident} ZIP Code.","type":"text","repeats":false,"readOnly":false,"maxLength":11,"id":"item.0.item.7"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1"}],"id":"item.0.item.8"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3"}],"id":"item.0.item.9"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1"}],"id":"item.0.item.10"},{"linkId":"Section-36/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.11"},{"linkId":"Section-36/A1400","prefix":"A1400","text":"Payer Information: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.12"},{"linkId":"Section-36/A0205","prefix":"A0205","text":"Site of Service at Admission","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.13"},{"linkId":"Section-36/A0245","prefix":"A0245","text":"Date Initial Nursing Assessment Initiated","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.14"}],"id":"item.0","description":"The patient must fill out Section A, which pertains to administrative information."},{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0","description":"The form asks the patient to enter their Medicaid number. If their Medicaid is still pending, they should enter \"+\". If they are not a Medicaid recipient, they should enter \"N\"."},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1","description":"What is the patient's gender? The options are male, female, or prefer not to say."},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2","description":"What is the patient's date of birth?"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3","description":"The type of record for the patient needs to be identified."},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4","description":"What is the reason for the patient's assessment?"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5","description":"What is the patient's admission date?"},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Admitted From. Immediately preceding this admission, where was the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.6","description":"Where was the patient immediately preceding this admission? Was the patient admitted from their home, another hospital, a nursing home, or somewhere else?"},{"linkId":"Section-36/A0550","prefix":"A0550","text":"{Patient/Resident} ZIP Code.","type":"text","repeats":false,"readOnly":false,"maxLength":11,"id":"item.0.item.7","description":"What is the patient's or resident's ZIP code?"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1"}],"id":"item.0.item.8","description":"The patient needs to provide the numbers associated with their facility provider."},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0","description":"What is the patient's National Provider Identifier (NPI)?"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1","description":"What is the patient's CMS Certification Number (CCN)?"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3"}],"id":"item.0.item.9","description":"What is the legal name of the patient or resident?"},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0","description":"What is the patient's first name?"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1","description":"What is the patient's middle initial?"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2","description":"What is the patient's last name?"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3","description":"What is the patient's suffix?"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1"}],"id":"item.0.item.10","description":"The form requests the patient's Social Security and Medicare numbers."},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0","description":"What is the patient's Social Security Number?"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1","description":"What is the patient's Medicare number?"},{"linkId":"Section-36/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.11","description":"The patient must check all the boxes that apply to their race or ethnicity."},{"linkId":"Section-36/A1400","prefix":"A1400","text":"Payer Information: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.12","description":"The patient should provide all applicable payer information by checking all the relevant options."},{"linkId":"Section-36/A0205","prefix":"A0205","text":"Site of Service at Admission","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.13","description":"What was the patient's site of service at the time of admission?"},{"linkId":"Section-36/A0245","prefix":"A0245","text":"Date Initial Nursing Assessment Initiated","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.14","description":"The date the initial nursing assessment for the patient was initiated."},{"linkId":"Section-47","text":"Section F: Preferences","type":"group","readOnly":true,"item":[{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0"},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1"}],"id":"item.1.item.0"},{"linkId":"Section-47/F2100","prefix":"F2100","text":"Other Life-Sustaining Treatment Preferences","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0"},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1"}],"id":"item.1.item.1"},{"linkId":"Section-47/F2200","prefix":"F2200","text":"Hospitalization Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0"},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1"}],"id":"item.1.item.2"},{"linkId":"Section-47/F3000","prefix":"F3000","text":"Spiritual/Existential Concerns","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0"},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1"}],"id":"item.1.item.3"}],"id":"item.1","description":"In section F of the form, the patient's preferences are discussed."},{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0"},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1"}],"id":"item.1.item.0","description":"Does the patient have a preference regarding CPR?"},{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0","description":"Was the patient, or the responsible party, asked about their preference regarding the use of cardiopulmonary resuscitation (CPR)? Please select the most accurate response."},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1","description":"The date when the patient or responsible party was first asked about their preference regarding the use of CPR."},{"linkId":"Section-47/F2100","prefix":"F2100","text":"Other Life-Sustaining Treatment Preferences","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0"},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1"}],"id":"item.1.item.1","description":"Does the patient have other life-sustaining treatment preferences?"},{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0","description":"Was the patient or responsible party asked about their preferences regarding life-sustaining treatments other than CPR? Please select the most accurate response."},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1","description":"The date on which the patient or responsible party was first asked about their preferences regarding life-sustaining treatments other than Cardiopulmonary Resuscitation was:"},{"linkId":"Section-47/F2200","prefix":"F2200","text":"Hospitalization Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0"},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1"}],"id":"item.1.item.2","description":"The patient has to choose their hospitalization preference."},{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0","description":"Was the patient or the responsible party asked about their preference regarding hospitalization? Please select the most accurate response."},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1","description":"The date that the patient, resident, or responsible party was first asked about their preference regarding hospitalization was:"},{"linkId":"Section-47/F3000","prefix":"F3000","text":"Spiritual/Existential Concerns","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0"},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1"}],"id":"item.1.item.3","description":"Does the patient have any spiritual or existential concerns?"},{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0","description":"Was the patient or resident and/or their caregiver asked about any spiritual or existential concerns? Please select the most accurate response."},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1","description":"When was the patient or their caregiver first asked about their spiritual or existential concerns?"},{"linkId":"Section-9","text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal Diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"}],"id":"item.2","description":"In Section I of the form, the patient's active diagnoses are listed."},{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal Diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"What is the patient's principal diagnosis?"},{"linkId":"Section-10","text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J0900","prefix":"J0900","text":"Pain Screening","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3"}],"id":"item.3.item.0"},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Pain Active Problem. Is pain an active problem for the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.1"},{"linkId":"Section-10/J0910","prefix":"J0910","text":"Comprehensive Pain Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2"}],"id":"item.3.item.2"},{"linkId":"Section-10/J2030","prefix":"J2030","text":"Screening for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2"}],"id":"item.3.item.3"},{"linkId":"Section-10/J2040","prefix":"J2040","text":"Treatment for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0"},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2"}],"id":"item.3.item.4"}],"id":"item.3","description":"In Section J of the form, the patient is asked about their health conditions."},{"linkId":"Section-10/J0900","prefix":"J0900","text":"Pain Screening","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3"}],"id":"item.3.item.0","description":"The patient is asked to participate in a pain screening."},{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0","description":"Was the patient or resident screened for pain?"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1","description":"When was the patient first screened for pain?"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2","description":"The severity of the patient's or resident's pain was:"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3","description":"The type of standardized pain tool used for the patient is:"},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Pain Active Problem. Is pain an active problem for the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.1","description":"Is pain an active problem for the patient or resident?"},{"linkId":"Section-10/J0910","prefix":"J0910","text":"Comprehensive Pain Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2"}],"id":"item.3.item.2","description":"The patient is required to fill out a comprehensive pain assessment."},{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0","description":"Was a comprehensive pain assessment conducted on the patient?"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1","description":"When was the date of the patient's comprehensive pain assessment?"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2","description":"The patient's form included a comprehensive pain assessment which stated: \"Check all that apply.\""},{"linkId":"Section-10/J2030","prefix":"J2030","text":"Screening for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2"}],"id":"item.3.item.3","description":"The patient is undergoing screening for shortness of breath."},{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0","description":"Was the patient or resident screened for symptoms of shortness of breath?"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1","description":"What was the date of the patient's first screening for shortness of breath?"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2","description":"Did the screening indicate that the patient had shortness of breath?"},{"linkId":"Section-10/J2040","prefix":"J2040","text":"Treatment for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0"},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2"}],"id":"item.3.item.4","description":"What is the patient's treatment for shortness of breath?"},{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0","description":"Was the treatment for the patient's shortness of breath initiated? Please select the most accurate response."},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1","description":"What is the date when the treatment for shortness of breath was initiated for the patient?"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2","description":"What types of treatment for shortness of breath has the patient initiated? Please check all that apply."},{"linkId":"Section-14","text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/N0500","prefix":"N0500","text":"Scheduled Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1"}],"id":"item.4.item.0"},{"linkId":"Section-14/N0510","prefix":"N0510","text":"PRN Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0"},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1"}],"id":"item.4.item.1"},{"linkId":"Section-14/N0520","prefix":"N0520","text":"Bowel Regimen - Complete only if {scheduled opioid or PRN opioid = yes}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0"},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1"}],"id":"item.4.item.2"}],"id":"item.4","description":"In Section N of the form, the patient is asked to provide information about their medications."},{"linkId":"Section-14/N0500","prefix":"N0500","text":"Scheduled Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1"}],"id":"item.4.item.0","description":"Does the patient have a scheduled opioid medication regimen?"},{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0","description":"Did the patient have a scheduled opioid initiated or continued?"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1","description":"The date the patient's opioid treatment was initiated or continued is scheduled for:"},{"linkId":"Section-14/N0510","prefix":"N0510","text":"PRN Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0"},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1"}],"id":"item.4.item.1","description":"Does the patient take opioid medication as needed?"},{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0","description":"Was a PRN opioid initiated or continued for the patient? The answer choices are: initiated, continued, or neither."},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1","description":"The date on which the patient's PRN opioid was initiated or continued."},{"linkId":"Section-14/N0520","prefix":"N0520","text":"Bowel Regimen - Complete only if {scheduled opioid or PRN opioid = yes}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0"},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1"}],"id":"item.4.item.2","description":"The patient should complete the section \"Bowel Regimen\" only if they are scheduled for opioid treatment or have been prescribed opioids on an as-needed basis."},{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0","description":"Was a bowel regimen initiated or continued for the patient? Please select the most accurate response."},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1","description":"The date when the patient's bowel regimen was initiated or continued is required."},{"linkId":"Section-50","text":"Section O: Service Utilization","type":"group","readOnly":true,"item":[{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.0"}],"id":"item.5","description":"In Section O of the form, the patient's service utilization is assessed."},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.0","description":"What was the level of care the patient received in the final 3 days?"},{"linkId":"Section-48","text":"Section Z: Record Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed 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Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1"}],"id":"item.6","description":"In section Z of the form, the administration records pertaining to the patient are documented."},{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0","description":"The signature of the person who completed the patient's assessment is required."},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0","description":"The patient is required to provide their signature, title, and date they completed section A."},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1","description":"The patient needs to provide their Signature, Title, ensure all Sections are filled out, and include the Date the Section was completed B."},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2","description":"The patient needs to provide their signature, title, and complete the sections required on the form. They should also include the date the section was completed, indicated as section C."},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3","description":"The patient filled out the signature, title, and sections, and completed section D on a specific date."},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4","description":"The sections of the form labeled \"Signature\", \"Title\", and \"Date Section Completed E\" should be filled out by the patient."},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5","description":"The form for the patient includes sections for signature, title, and the date when the section was completed."},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6","description":"The patient's signature, title, and the date the section was completed are all required in Section G."},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7","description":"The patient is required to provide their signature and title in the designated sections, and also specify the date when the section was completed."},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8","description":"The patient needs to provide their signature, title, and the sections they have completed on the form, along with the date the section was finished."},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9","description":"The patient is required to provide their signature, title, and date for each completed section on the form."},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10","description":"The patient is required to provide their signature, title, and date on the sections they have completed in Section K."},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11","description":"The patient must provide their signature, title, and date in the sections indicated upon completion."},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1","description":"The signature of the RN Coordinator is required to verify the completion of the patient's assessment."},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0","description":"The form requires the patient's signature."},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1","description":"The date on which the Registered Nurse Assessment Coordinator signed the patient's assessment as complete."},null],"_id":"XTrA6TyitKM4h4zRw"} {"responseType":"QuestionnaireResponse","questionnaire":"HIS-HA-2.00.0","id":"HIS-HA-2.00.0-1","title":"Hospice Item Set - Hospice Admission Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-09-20T06:29:57.933Z","item":[{"linkId":"Section-36","text":"Section A: Administrative Information","type":"group","readOnly":true,"item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0"},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3"},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5"},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Admitted From. Immediately preceding this admission, where was the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.6"},{"linkId":"Section-36/A0550","prefix":"A0550","text":"{Patient/Resident} ZIP Code.","type":"text","repeats":false,"readOnly":false,"maxLength":11,"id":"item.0.item.7"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1"}],"id":"item.0.item.8"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3"}],"id":"item.0.item.9"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1"}],"id":"item.0.item.10"},{"linkId":"Section-36/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.11"},{"linkId":"Section-36/A1400","prefix":"A1400","text":"Payer Information: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.12"},{"linkId":"Section-36/A0205","prefix":"A0205","text":"Site of Service at Admission","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.13"},{"linkId":"Section-36/A0245","prefix":"A0245","text":"Date Initial Nursing Assessment Initiated","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.14"}],"id":"item.0","description":"The patient must fill out Section A, which pertains to administrative information."},{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0","description":"The form asks the patient to enter their Medicaid number. If their Medicaid is still pending, they should enter \"+\". If they are not a Medicaid recipient, they should enter \"N\"."},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1","description":"What is the patient's gender? The options are male, female, or prefer not to say."},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2","description":"What is the patient's date of birth?"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3","description":"The type of record for the patient needs to be identified."},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4","description":"What is the reason for the patient's assessment?"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5","description":"What is the patient's admission date?"},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Admitted From. Immediately preceding this admission, where was the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.6","description":"Where was the patient immediately preceding this admission? Was the patient admitted from their home, another hospital, a nursing home, or somewhere else?"},{"linkId":"Section-36/A0550","prefix":"A0550","text":"{Patient/Resident} ZIP Code.","type":"text","repeats":false,"readOnly":false,"maxLength":11,"id":"item.0.item.7","description":"What is the patient's or resident's ZIP code?"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1"}],"id":"item.0.item.8","description":"The patient needs to provide the numbers associated with their facility provider."},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0","description":"What is the patient's National Provider Identifier (NPI)?"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1","description":"What is the patient's CMS Certification Number (CCN)?"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3"}],"id":"item.0.item.9","description":"What is the legal name of the patient or resident?"},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0","description":"What is the patient's first name?"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1","description":"What is the patient's middle initial?"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2","description":"What is the patient's last name?"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3","description":"What is the patient's suffix?"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1"}],"id":"item.0.item.10","description":"The form requests the patient's Social Security and Medicare numbers."},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0","description":"What is the patient's Social Security Number?"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1","description":"What is the patient's Medicare number?"},{"linkId":"Section-36/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.11","description":"The patient must check all the boxes that apply to their race or ethnicity."},{"linkId":"Section-36/A1400","prefix":"A1400","text":"Payer Information: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.12","description":"The patient should provide all applicable payer information by checking all the relevant options."},{"linkId":"Section-36/A0205","prefix":"A0205","text":"Site of Service at Admission","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.13","description":"What was the patient's site of service at the time of admission?"},{"linkId":"Section-36/A0245","prefix":"A0245","text":"Date Initial Nursing Assessment Initiated","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.14","description":"The date the initial nursing assessment for the patient was initiated."},{"linkId":"Section-47","text":"Section F: Preferences","type":"group","readOnly":true,"item":[{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0"},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1"}],"id":"item.1.item.0"},{"linkId":"Section-47/F2100","prefix":"F2100","text":"Other Life-Sustaining Treatment Preferences","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0"},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1"}],"id":"item.1.item.1"},{"linkId":"Section-47/F2200","prefix":"F2200","text":"Hospitalization Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0"},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1"}],"id":"item.1.item.2"},{"linkId":"Section-47/F3000","prefix":"F3000","text":"Spiritual/Existential Concerns","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0"},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1"}],"id":"item.1.item.3"}],"id":"item.1","description":"In section F of the form, the patient's preferences are discussed."},{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0"},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1"}],"id":"item.1.item.0","description":"Does the patient have a preference regarding CPR?"},{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0","description":"Was the patient, or the responsible party, asked about their preference regarding the use of cardiopulmonary resuscitation (CPR)? Please select the most accurate response."},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1","description":"The date when the patient or responsible party was first asked about their preference regarding the use of CPR."},{"linkId":"Section-47/F2100","prefix":"F2100","text":"Other Life-Sustaining Treatment Preferences","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0"},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1"}],"id":"item.1.item.1","description":"Does the patient have other life-sustaining treatment preferences?"},{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0","description":"Was the patient or responsible party asked about their preferences regarding life-sustaining treatments other than CPR? Please select the most accurate response."},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1","description":"The date on which the patient or responsible party was first asked about their preferences regarding life-sustaining treatments other than Cardiopulmonary Resuscitation was:"},{"linkId":"Section-47/F2200","prefix":"F2200","text":"Hospitalization Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0"},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1"}],"id":"item.1.item.2","description":"The patient has to choose their hospitalization preference."},{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0","description":"Was the patient or the responsible party asked about their preference regarding hospitalization? Please select the most accurate response."},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1","description":"The date that the patient, resident, or responsible party was first asked about their preference regarding hospitalization was:"},{"linkId":"Section-47/F3000","prefix":"F3000","text":"Spiritual/Existential Concerns","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0"},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1"}],"id":"item.1.item.3","description":"Does the patient have any spiritual or existential concerns?"},{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0","description":"Was the patient or resident and/or their caregiver asked about any spiritual or existential concerns? Please select the most accurate response."},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1","description":"When was the patient or their caregiver first asked about their spiritual or existential concerns?"},{"linkId":"Section-9","text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal Diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"}],"id":"item.2","description":"In Section I of the form, the patient's active diagnoses are listed."},{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal Diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"What is the patient's principal diagnosis?"},{"linkId":"Section-10","text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J0900","prefix":"J0900","text":"Pain Screening","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3"}],"id":"item.3.item.0"},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Pain Active Problem. Is pain an active problem for the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.1"},{"linkId":"Section-10/J0910","prefix":"J0910","text":"Comprehensive Pain Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2"}],"id":"item.3.item.2"},{"linkId":"Section-10/J2030","prefix":"J2030","text":"Screening for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2"}],"id":"item.3.item.3"},{"linkId":"Section-10/J2040","prefix":"J2040","text":"Treatment for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0"},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2"}],"id":"item.3.item.4"}],"id":"item.3","description":"In Section J of the form, the patient is asked about their health conditions."},{"linkId":"Section-10/J0900","prefix":"J0900","text":"Pain Screening","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3"}],"id":"item.3.item.0","description":"The patient is asked to participate in a pain screening."},{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0","description":"Was the patient or resident screened for pain?"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1","description":"When was the patient first screened for pain?"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2","description":"The severity of the patient's or resident's pain was:"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3","description":"The type of standardized pain tool used for the patient is:"},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Pain Active Problem. Is pain an active problem for the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.1","description":"Is pain an active problem for the patient or resident?"},{"linkId":"Section-10/J0910","prefix":"J0910","text":"Comprehensive Pain Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2"}],"id":"item.3.item.2","description":"The patient is required to fill out a comprehensive pain assessment."},{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0","description":"Was a comprehensive pain assessment conducted on the patient?"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1","description":"When was the date of the patient's comprehensive pain assessment?"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2","description":"The patient's form included a comprehensive pain assessment which stated: \"Check all that apply.\""},{"linkId":"Section-10/J2030","prefix":"J2030","text":"Screening for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2"}],"id":"item.3.item.3","description":"The patient is undergoing screening for shortness of breath."},{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0","description":"Was the patient or resident screened for symptoms of shortness of breath?"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1","description":"What was the date of the patient's first screening for shortness of breath?"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2","description":"Did the screening indicate that the patient had shortness of breath?"},{"linkId":"Section-10/J2040","prefix":"J2040","text":"Treatment for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0"},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2"}],"id":"item.3.item.4","description":"What is the patient's treatment for shortness of breath?"},{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0","description":"Was the treatment for the patient's shortness of breath initiated? Please select the most accurate response."},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1","description":"What is the date when the treatment for shortness of breath was initiated for the patient?"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2","description":"What types of treatment for shortness of breath has the patient initiated? Please check all that apply."},{"linkId":"Section-14","text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/N0500","prefix":"N0500","text":"Scheduled Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1"}],"id":"item.4.item.0"},{"linkId":"Section-14/N0510","prefix":"N0510","text":"PRN Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0"},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1"}],"id":"item.4.item.1"},{"linkId":"Section-14/N0520","prefix":"N0520","text":"Bowel Regimen - Complete only if {scheduled opioid or PRN opioid = yes}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0"},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1"}],"id":"item.4.item.2"}],"id":"item.4","description":"In Section N of the form, the patient is asked to provide information about their medications."},{"linkId":"Section-14/N0500","prefix":"N0500","text":"Scheduled Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1"}],"id":"item.4.item.0","description":"Does the patient have a scheduled opioid medication regimen?"},{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0","description":"Did the patient have a scheduled opioid initiated or continued?"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1","description":"The date the patient's opioid treatment was initiated or continued is scheduled for:"},{"linkId":"Section-14/N0510","prefix":"N0510","text":"PRN Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0"},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1"}],"id":"item.4.item.1","description":"Does the patient take opioid medication as needed?"},{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0","description":"Was a PRN opioid initiated or continued for the patient? The answer choices are: initiated, continued, or neither."},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1","description":"The date on which the patient's PRN opioid was initiated or continued."},{"linkId":"Section-14/N0520","prefix":"N0520","text":"Bowel Regimen - Complete only if {scheduled opioid or PRN opioid = yes}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0"},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1"}],"id":"item.4.item.2","description":"The patient should complete the section \"Bowel Regimen\" only if they are scheduled for opioid treatment or have been prescribed opioids on an as-needed basis."},{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0","description":"Was a bowel regimen initiated or continued for the patient? Please select the most accurate response."},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1","description":"The date when the patient's bowel regimen was initiated or continued is required."},{"linkId":"Section-50","text":"Section O: Service Utilization","type":"group","readOnly":true,"item":[{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.0"}],"id":"item.5","description":"In Section O of the form, the patient's service utilization is assessed."},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.0","description":"What was the level of care the patient received in the final 3 days?"},{"linkId":"Section-48","text":"Section Z: Record Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0"},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1"}],"id":"item.6","description":"In section Z of the form, the administration records pertaining to the patient are documented."},{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0","description":"The signature of the person who completed the patient's assessment is required."},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0","description":"The patient is required to provide their signature, title, and date they completed section A."},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1","description":"The patient needs to provide their Signature, Title, ensure all Sections are filled out, and include the Date the Section was completed B."},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2","description":"The patient needs to provide their signature, title, and complete the sections required on the form. They should also include the date the section was completed, indicated as section C."},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3","description":"The patient filled out the signature, title, and sections, and completed section D on a specific date."},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4","description":"The sections of the form labeled \"Signature\", \"Title\", and \"Date Section Completed E\" should be filled out by the patient."},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5","description":"The form for the patient includes sections for signature, title, and the date when the section was completed."},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6","description":"The patient's signature, title, and the date the section was completed are all required in Section G."},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7","description":"The patient is required to provide their signature and title in the designated sections, and also specify the date when the section was completed."},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8","description":"The patient needs to provide their signature, title, and the sections they have completed on the form, along with the date the section was finished."},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9","description":"The patient is required to provide their signature, title, and date for each completed section on the form."},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10","description":"The patient is required to provide their signature, title, and date on the sections they have completed in Section K."},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11","description":"The patient must provide their signature, title, and date in the sections indicated upon completion."},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1","description":"The signature of the RN Coordinator is required to verify the completion of the patient's assessment."},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0","description":"The form requires the patient's signature."},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1","description":"The date on which the Registered Nurse Assessment Coordinator signed the patient's assessment as complete."},null],"_id":"LfAAd2JQXLaCpopSb"} {"responseType":"QuestionnaireResponse","questionnaire":"HIS-HD-2.00.0","id":"HIS-HD-2.00.0-1","title":"Hospice Item Set - Hospice Discharge Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-09-20T06:33:39.936Z","item":[{"linkId":"Section-36","text":"Section A: Administrative Information","type":"group","readOnly":true,"item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0"},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3"},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5"},{"linkId":"Section-36/A0270","prefix":"A0270","text":"Discharge Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.6"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1"}],"id":"item.0.item.7"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3"}],"id":"item.0.item.8"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1"}],"id":"item.0.item.9"},{"linkId":"Section-36/A2115","prefix":"A2115","text":"Reason for Discharge","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.10"}],"id":"item.0","description":"The section A on the form is for administrative information about the patient."},{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0","description":"The form asks for the patient's Medicaid Number. They should enter \"+\" if their Medicaid application is pending, or \"N\" if they are not a Medicaid recipient."},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1","description":"What is the patient's gender?"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2","description":"What is the patient's birth date?"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3","description":"The type of record pertaining to the patient needs to be identified."},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4","description":"The reason for the patient's assessment should be clearly specified."},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5","description":"What is the patient's admission date?"},{"linkId":"Section-36/A0270","prefix":"A0270","text":"Discharge Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.6","description":"What is the patient's discharge date?"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1"}],"id":"item.0.item.7","description":"The facility has designated provider numbers for the patient."},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0","description":"What is the patient's National Provider Identifier (NPI)?"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1","description":"The patient needs to provide their CMS Certification Number (CCN)."},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3"}],"id":"item.0.item.8","description":"What is the legal name of the patient or resident?"},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0","description":"What is the patient's first name?"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1","description":"What is the patient's middle initial?"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2","description":"What is the patient's last name?"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3","description":"What is the patient's suffix?"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1"}],"id":"item.0.item.9","description":"The patient needs to provide their Social Security and Medicare numbers."},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0","description":"What is the patient's Social Security Number?"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1","description":"What is the patient's Medicare number?"},{"linkId":"Section-36/A2115","prefix":"A2115","text":"Reason for Discharge","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.10","description":"What is the reason for the patient's discharge?"},{"linkId":"Section-47","text":"Section F: Preferences","type":"group","readOnly":true,"item":[{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR preference","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.1.item.0"}],"id":"item.1","description":"In section F of the form, the patient's preferences are to be indicated."},{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR preference","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.1.item.0","description":"What is the patient's preference regarding CPR?"},{"linkId":"Section-9","text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"}],"id":"item.2","description":"In Section I of the form, the active diagnoses of the patient are listed."},{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"The principal diagnosis for the patient is still undetermined."},{"linkId":"Section-10","text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J0100","prefix":"J0100","text":"Pain Management","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.3.item.0"}],"id":"item.3","description":"In Section J of the form, the patient is asked to provide information about their health conditions."},{"linkId":"Section-10/J0100","prefix":"J0100","text":"Pain Management","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.3.item.0","description":"Does the patient require pain management?"},{"linkId":"Section-14","text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/M2003","prefix":"M2003","text":"Medication follow-up","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.4.item.0"}],"id":"item.4","description":"In Section N of the form, it asks about the patient's medications."},{"linkId":"Section-14/M2003","prefix":"M2003","text":"Medication follow-up","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.4.item.0","description":"Does the patient require a medication follow-up?"},{"linkId":"Section-50","text":"Section O: Service Utilization","type":"group","readOnly":true,"item":[{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.0"},{"linkId":"Section-50/O5010","prefix":"O5010","text":"Number of hospice visits in final 3 days. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0"},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1"},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2"}],"id":"item.5.item.1"},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Registered Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.2"},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"Registered Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.3"},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"Registered Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.4"},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.5"},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.6"},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.7"},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"Medical Social Worker - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.8"},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"Medical Social Worker - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.9"},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"Medical Social Worker - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.10"},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Chaplain or Spiritual Counselor - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.11"},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Chaplain or Spiritual Counselor -Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.12"},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Chaplain or Spiritual Counselor - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.13"},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Licensed Professional Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.14"},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Licensed Professional Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.15"},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Licensed Professional Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.16"},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Aide - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.17"},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Aide - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.18"},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Aide - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.19"},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Level of care in final 7 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.20"},{"linkId":"Section-50/O5030","prefix":"O5030","text":"Number of hospice visits in 3 to 6 days prior to death. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3"}],"id":"item.5.item.21"},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"Registered Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.22"},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"Registered Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.23"},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"Registered Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.24"},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"Registered Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.25"},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.26"},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.27"},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.28"},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.29"},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Medical Social Worker - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.30"},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"Medical Social Worker - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.31"},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"Medical Social Worker - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.32"},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"Medical Social Worker - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.33"},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Chaplain or Spiritual Counselor - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.34"},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"Chaplain or Spiritual Counselor - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.35"},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"Chaplain or Spiritual Counselor - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.36"},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Chaplain or Spiritual Counselor - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.37"},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"Licensed Professional Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.38"},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"Licensed Professional Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.39"},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Licensed Professional Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.40"},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"Licensed Professional Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.41"},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Aide - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.42"},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"Aide - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.43"},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Aide - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.44"},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Aide - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.45"}],"id":"item.5","description":"In section O of the form, the patient's service utilization is assessed."},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.0","description":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final three days of their life?"},{"linkId":"Section-50/O5010","prefix":"O5010","text":"Number of hospice visits in final 3 days. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0"},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1"},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2"}],"id":"item.5.item.1","description":"The form requires the patient to enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated, specifically focusing on the final three days of hospice care."},{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0","description":"The number of hospice visits the patient had on the day of their death."},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1","description":"The form asked the patient how many hospice visits they had one day prior to their death."},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2","description":"How many hospice visits did the patient have two days prior to death?"},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Registered Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.2","description":"Did the registered nurse visit the patient on the day of death?"},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"Registered Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.3","description":"The registered nurse visited the patient one day prior to their death."},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"Registered Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.4","description":"Did the registered nurse visit the patient two days prior to their death?"},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.5","description":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant on the day of their death?"},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.6","description":"Did the patient have a visit from a physician, nurse practitioner, or physician assistant one day prior to their death?"},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.7","description":"Did the patient visit a physician, nurse practitioner, or physician assistant two days prior to their death?"},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"Medical Social Worker - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.8","description":"Did the medical social worker visit the patient on the day of their death?"},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"Medical Social Worker - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.9","description":"The medical social worker visited the patient one day prior to their death."},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"Medical Social Worker - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.10","description":"The medical social worker visited the patient two days prior to their death."},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Chaplain or Spiritual Counselor - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.11","description":"Did the patient receive a visit from a Chaplain or Spiritual Counselor on the day of their death?"},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Chaplain or Spiritual Counselor -Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.12","description":"Did the patient receive a visit from a chaplain or spiritual counselor one day prior to their death?"},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Chaplain or Spiritual Counselor - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.13","description":"Did the patient receive a visit from a chaplain or spiritual counselor two days prior to death?"},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Licensed Professional Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.14","description":"Did the Licensed Professional Nurse visit the patient on the day of their death?"},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Licensed Professional Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.15","description":"Did the licensed professional nurse visit the patient one day prior to their death?"},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Licensed Professional Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.16","description":"The patient was visited by a Licensed Professional Nurse two days prior to their death."},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Aide - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.17","description":"Did the aide visit the patient on the day of death?"},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Aide - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.18","description":"Did the aide visit the patient one day prior to their death?"},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Aide - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.19","description":"Did the patient receive an aide visit two days prior to death?"},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Level of care in final 7 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.20","description":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final seven days of their life?"},{"linkId":"Section-50/O5030","prefix":"O5030","text":"Number of hospice visits in 3 to 6 days prior to death. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3"}],"id":"item.5.item.21","description":"The form is asking for the number of visits the patient received from hospice staff in the 3 to 6 days prior to their death. The respondent should enter the number of visits provided by hospice staff from the indicated discipline, on each of the specified dates."},{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0","description":"How many hospice visits did the patient have three days prior to death?"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1","description":"How many hospice visits did the patient have four days prior to death in the period of 3 to 6 days before death?"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2","description":"How many hospice visits did the patient have five days prior to death?"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3","description":"How many hospice visits did the patient have in the six days prior to their death?"},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"Registered Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.22","description":"The patient was visited by a registered nurse three days prior to their death."},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"Registered Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.23","description":"The registered nurse visited the patient four days prior to their death."},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"Registered Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.24","description":"The registered nurse visited the patient five days prior to their death."},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"Registered Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.25","description":"The registered nurse visited the patient six days prior to their death."},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.26","description":"Did the patient visit a physician, nurse practitioner, or physician assistant three days prior to death?"},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.27","description":"The patient visited the physician, nurse practitioner, or physician assistant four days prior to their death."},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.28","description":"Did the patient visit a physician, nurse practitioner, or physician assistant five days prior to their death?"},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.29","description":"The patient was visited by a physician, nurse practitioner, or physician assistant six days prior to death."},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Medical Social Worker - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.30","description":"The medical social worker visited the patient three days prior to their death."},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"Medical Social Worker - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.31","description":"The medical social worker visited the patient four days prior to their death."},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"Medical Social Worker - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.32","description":"The medical social worker visited the patient five days prior to their death."},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"Medical Social Worker - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.33","description":"The medical social worker visited the patient six days prior to their death."},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Chaplain or Spiritual Counselor - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.34","description":"Did the patient receive a visit from a chaplain or spiritual counselor three days prior to death?"},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"Chaplain or Spiritual Counselor - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.35","description":"Did the patient receive a visit from a chaplain or spiritual counselor four days prior to death?"},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"Chaplain or Spiritual Counselor - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.36","description":"Did the patient receive visits from a chaplain or spiritual counselor five days prior to death?"},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Chaplain or Spiritual Counselor - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.37","description":"Did the patient receive a visit from a chaplain or spiritual counselor six days prior to death?"},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"Licensed Professional Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.38","description":"The licensed professional nurse visited the patient three days prior to their death."},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"Licensed Professional Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.39","description":"The Licensed Professional Nurse visited the patient four days prior to their death."},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Licensed Professional Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.40","description":"The patient was visited by a licensed professional nurse five days prior to their death."},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"Licensed Professional Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.41","description":"The Licensed Professional Nurse visited the patient six days prior to their death."},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Aide - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.42","description":"The patient had visits from an aide three days prior to their death."},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"Aide - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.43","description":"Did the aide visit the patient four days prior to death?"},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Aide - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.44","description":"Did the patient receive aid visits five days prior to death?"},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Aide - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.45","description":"Did the aide visit the patient six days prior to death?"},{"linkId":"Section-48","text":"Section Z: Record Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0"},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1"}],"id":"item.6","description":"In Section Z, the record administration pertaining to the patient needs to be filled out."},{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0","description":"The signature of the person who completed the patient's assessment is required."},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0","description":"The patient needs to provide their signature, title, and the date on which they completed section A."},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1","description":"The patient is required to provide their signature and title, and then complete section B, after which they must record the date the section was completed."},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2","description":"The patient should provide their signature, title, and date in the section marked 'C'."},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3","description":"The patient was required to provide their signature and title, fill out several sections, and note down the date they completed section D."},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4","description":"\"The patient is required to provide a signature, title, and complete various sections. They also need to provide the date on which the section E was completed.\""},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5","description":"The patient completed the sections of the form and signed it, indicating their title and date when they finished section F."},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6","description":"The patient needs to provide their signature, title, and the date the sections were completed in Section G."},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7","description":"The patient needs to provide their signature, title, and the date on which the form section H was completed."},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8","description":"The patient is required to provide their signature, title, the sections they have completed, and the date on which the section was completed."},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9","description":"The patient's form includes their signature, title, date, and the sections they completed, specifically section J."},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10","description":"The patient is required to provide their signature, title, and the date on which the sections were completed."},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11","description":"The form for the patient includes sections for a signature, title, and the date when the section was completed."},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1","description":"The signature of the RN Coordinator is required to verify the completion of the patient's assessment."},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0","description":"The form requires the patient's signature."},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1","description":"The date when the Registered Nurse Assessment Coordinator signed the patient's assessment as complete."},null],"_id":"EkrfQrL483LfkRwoN"} {"responseType":"QuestionnaireResponse","questionnaire":"HIS-HD-2.00.0","id":"HIS-HD-2.00.0-1","title":"Hospice Item Set - Hospice Discharge Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-09-20T06:33:39.936Z","item":[{"linkId":"Section-36","text":"Section A: Administrative Information","type":"group","readOnly":true,"item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0"},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3"},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5"},{"linkId":"Section-36/A0270","prefix":"A0270","text":"Discharge Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.6"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1"}],"id":"item.0.item.7"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3"}],"id":"item.0.item.8"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1"}],"id":"item.0.item.9"},{"linkId":"Section-36/A2115","prefix":"A2115","text":"Reason for Discharge","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.10"}],"id":"item.0","description":"The section A on the form is for administrative information about the patient."},{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0","description":"The form asks for the patient's Medicaid Number. They should enter \"+\" if their Medicaid application is pending, or \"N\" if they are not a Medicaid recipient."},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1","description":"What is the patient's gender?"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2","description":"What is the patient's birth date?"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3","description":"The type of record pertaining to the patient needs to be identified."},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4","description":"The reason for the patient's assessment should be clearly specified."},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5","description":"What is the patient's admission date?"},{"linkId":"Section-36/A0270","prefix":"A0270","text":"Discharge Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.6","description":"What is the patient's discharge date?"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1"}],"id":"item.0.item.7","description":"The facility has designated provider numbers for the patient."},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0","description":"What is the patient's National Provider Identifier (NPI)?"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1","description":"The patient needs to provide their CMS Certification Number (CCN)."},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3"}],"id":"item.0.item.8","description":"What is the legal name of the patient or resident?"},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0","description":"What is the patient's first name?"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1","description":"What is the patient's middle initial?"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2","description":"What is the patient's last name?"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3","description":"What is the patient's suffix?"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1"}],"id":"item.0.item.9","description":"The patient needs to provide their Social Security and Medicare numbers."},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0","description":"What is the patient's Social Security Number?"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1","description":"What is the patient's Medicare number?"},{"linkId":"Section-36/A2115","prefix":"A2115","text":"Reason for Discharge","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.10","description":"What is the reason for the patient's discharge?"},{"linkId":"Section-47","text":"Section F: Preferences","type":"group","readOnly":true,"item":[{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR preference","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.1.item.0"}],"id":"item.1","description":"In section F of the form, the patient's preferences are to be indicated."},{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR preference","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.1.item.0","description":"What is the patient's preference regarding CPR?"},{"linkId":"Section-9","text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"}],"id":"item.2","description":"In Section I of the form, the active diagnoses of the patient are listed."},{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"The principal diagnosis for the patient is still undetermined."},{"linkId":"Section-10","text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J0100","prefix":"J0100","text":"Pain Management","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.3.item.0"}],"id":"item.3","description":"In Section J of the form, the patient is asked to provide information about their health conditions."},{"linkId":"Section-10/J0100","prefix":"J0100","text":"Pain Management","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.3.item.0","description":"Does the patient require pain management?"},{"linkId":"Section-14","text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/M2003","prefix":"M2003","text":"Medication follow-up","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.4.item.0"}],"id":"item.4","description":"In Section N of the form, it asks about the patient's medications."},{"linkId":"Section-14/M2003","prefix":"M2003","text":"Medication follow-up","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.4.item.0","description":"Does the patient require a medication follow-up?"},{"linkId":"Section-50","text":"Section O: Service Utilization","type":"group","readOnly":true,"item":[{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.0"},{"linkId":"Section-50/O5010","prefix":"O5010","text":"Number of hospice visits in final 3 days. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0"},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1"},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2"}],"id":"item.5.item.1"},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Registered Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.2"},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"Registered Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.3"},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"Registered Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.4"},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.5"},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.6"},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.7"},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"Medical Social Worker - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.8"},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"Medical Social Worker - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.9"},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"Medical Social Worker - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.10"},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Chaplain or Spiritual Counselor - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.11"},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Chaplain or Spiritual Counselor -Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.12"},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Chaplain or Spiritual Counselor - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.13"},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Licensed Professional Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.14"},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Licensed Professional Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.15"},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Licensed Professional Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.16"},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Aide - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.17"},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Aide - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.18"},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Aide - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.19"},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Level of care in final 7 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.20"},{"linkId":"Section-50/O5030","prefix":"O5030","text":"Number of hospice visits in 3 to 6 days prior to death. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3"}],"id":"item.5.item.21"},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"Registered Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.22"},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"Registered Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.23"},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"Registered Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.24"},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"Registered Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.25"},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.26"},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.27"},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.28"},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.29"},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Medical Social Worker - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.30"},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"Medical Social Worker - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.31"},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"Medical Social Worker - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.32"},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"Medical Social Worker - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.33"},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Chaplain or Spiritual Counselor - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.34"},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"Chaplain or Spiritual Counselor - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.35"},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"Chaplain or Spiritual Counselor - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.36"},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Chaplain or Spiritual Counselor - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.37"},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"Licensed Professional Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.38"},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"Licensed Professional Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.39"},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Licensed Professional Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.40"},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"Licensed Professional Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.41"},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Aide - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.42"},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"Aide - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.43"},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Aide - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.44"},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Aide - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.45"}],"id":"item.5","description":"In section O of the form, the patient's service utilization is assessed."},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.0","description":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final three days of their life?"},{"linkId":"Section-50/O5010","prefix":"O5010","text":"Number of hospice visits in final 3 days. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0"},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1"},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2"}],"id":"item.5.item.1","description":"The form requires the patient to enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated, specifically focusing on the final three days of hospice care."},{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0","description":"The number of hospice visits the patient had on the day of their death."},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1","description":"The form asked the patient how many hospice visits they had one day prior to their death."},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2","description":"How many hospice visits did the patient have two days prior to death?"},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Registered Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.2","description":"Did the registered nurse visit the patient on the day of death?"},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"Registered Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.3","description":"The registered nurse visited the patient one day prior to their death."},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"Registered Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.4","description":"Did the registered nurse visit the patient two days prior to their death?"},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.5","description":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant on the day of their death?"},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.6","description":"Did the patient have a visit from a physician, nurse practitioner, or physician assistant one day prior to their death?"},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.7","description":"Did the patient visit a physician, nurse practitioner, or physician assistant two days prior to their death?"},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"Medical Social Worker - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.8","description":"Did the medical social worker visit the patient on the day of their death?"},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"Medical Social Worker - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.9","description":"The medical social worker visited the patient one day prior to their death."},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"Medical Social Worker - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.10","description":"The medical social worker visited the patient two days prior to their death."},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Chaplain or Spiritual Counselor - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.11","description":"Did the patient receive a visit from a Chaplain or Spiritual Counselor on the day of their death?"},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Chaplain or Spiritual Counselor -Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.12","description":"Did the patient receive a visit from a chaplain or spiritual counselor one day prior to their death?"},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Chaplain or Spiritual Counselor - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.13","description":"Did the patient receive a visit from a chaplain or spiritual counselor two days prior to death?"},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Licensed Professional Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.14","description":"Did the Licensed Professional Nurse visit the patient on the day of their death?"},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Licensed Professional Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.15","description":"Did the licensed professional nurse visit the patient one day prior to their death?"},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Licensed Professional Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.16","description":"The patient was visited by a Licensed Professional Nurse two days prior to their death."},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Aide - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.17","description":"Did the aide visit the patient on the day of death?"},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Aide - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.18","description":"Did the aide visit the patient one day prior to their death?"},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Aide - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.19","description":"Did the patient receive an aide visit two days prior to death?"},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Level of care in final 7 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.20","description":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final seven days of their life?"},{"linkId":"Section-50/O5030","prefix":"O5030","text":"Number of hospice visits in 3 to 6 days prior to death. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3"}],"id":"item.5.item.21","description":"The form is asking for the number of visits the patient received from hospice staff in the 3 to 6 days prior to their death. The respondent should enter the number of visits provided by hospice staff from the indicated discipline, on each of the specified dates."},{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0","description":"How many hospice visits did the patient have three days prior to death?"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1","description":"How many hospice visits did the patient have four days prior to death in the period of 3 to 6 days before death?"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2","description":"How many hospice visits did the patient have five days prior to death?"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3","description":"How many hospice visits did the patient have in the six days prior to their death?"},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"Registered Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.22","description":"The patient was visited by a registered nurse three days prior to their death."},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"Registered Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.23","description":"The registered nurse visited the patient four days prior to their death."},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"Registered Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.24","description":"The registered nurse visited the patient five days prior to their death."},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"Registered Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.25","description":"The registered nurse visited the patient six days prior to their death."},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.26","description":"Did the patient visit a physician, nurse practitioner, or physician assistant three days prior to death?"},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.27","description":"The patient visited the physician, nurse practitioner, or physician assistant four days prior to their death."},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.28","description":"Did the patient visit a physician, nurse practitioner, or physician assistant five days prior to their death?"},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.29","description":"The patient was visited by a physician, nurse practitioner, or physician assistant six days prior to death."},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Medical Social Worker - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.30","description":"The medical social worker visited the patient three days prior to their death."},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"Medical Social Worker - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.31","description":"The medical social worker visited the patient four days prior to their death."},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"Medical Social Worker - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.32","description":"The medical social worker visited the patient five days prior to their death."},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"Medical Social Worker - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.33","description":"The medical social worker visited the patient six days prior to their death."},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Chaplain or Spiritual Counselor - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.34","description":"Did the patient receive a visit from a chaplain or spiritual counselor three days prior to death?"},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"Chaplain or Spiritual Counselor - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.35","description":"Did the patient receive a visit from a chaplain or spiritual counselor four days prior to death?"},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"Chaplain or Spiritual Counselor - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.36","description":"Did the patient receive visits from a chaplain or spiritual counselor five days prior to death?"},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Chaplain or Spiritual Counselor - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.37","description":"Did the patient receive a visit from a chaplain or spiritual counselor six days prior to death?"},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"Licensed Professional Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.38","description":"The licensed professional nurse visited the patient three days prior to their death."},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"Licensed Professional Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.39","description":"The Licensed Professional Nurse visited the patient four days prior to their death."},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Licensed Professional Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.40","description":"The patient was visited by a licensed professional nurse five days prior to their death."},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"Licensed Professional Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.41","description":"The Licensed Professional Nurse visited the patient six days prior to their death."},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Aide - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.42","description":"The patient had visits from an aide three days prior to their death."},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"Aide - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.43","description":"Did the aide visit the patient four days prior to death?"},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Aide - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.44","description":"Did the patient receive aid visits five days prior to death?"},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Aide - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.45","description":"Did the aide visit the patient six days prior to death?"},{"linkId":"Section-48","text":"Section Z: Record Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0"},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1"}],"id":"item.6","description":"In Section Z, the record administration pertaining to the patient needs to be filled out."},{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0","description":"The signature of the person who completed the patient's assessment is required."},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0","description":"The patient needs to provide their signature, title, and the date on which they completed section A."},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1","description":"The patient is required to provide their signature and title, and then complete section B, after which they must record the date the section was completed."},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2","description":"The patient should provide their signature, title, and date in the section marked 'C'."},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3","description":"The patient was required to provide their signature and title, fill out several sections, and note down the date they completed section D."},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4","description":"\"The patient is required to provide a signature, title, and complete various sections. They also need to provide the date on which the section E was completed.\""},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5","description":"The patient completed the sections of the form and signed it, indicating their title and date when they finished section F."},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6","description":"The patient needs to provide their signature, title, and the date the sections were completed in Section G."},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7","description":"The patient needs to provide their signature, title, and the date on which the form section H was completed."},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8","description":"The patient is required to provide their signature, title, the sections they have completed, and the date on which the section was completed."},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9","description":"The patient's form includes their signature, title, date, and the sections they completed, specifically section J."},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10","description":"The patient is required to provide their signature, title, and the date on which the sections were completed."},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11","description":"The form for the patient includes sections for a signature, title, and the date when the section was completed."},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1","description":"The signature of the RN Coordinator is required to verify the completion of the patient's assessment."},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0","description":"The form requires the patient's signature."},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1","description":"The date when the Registered Nurse Assessment Coordinator signed the patient's assessment as complete."},null],"_id":"oiSp98rgWZf9tcjPW"} {"responseType":"QuestionnaireResponse","questionnaire":"HIS-HD-2.00.0","id":"HIS-HD-2.00.0-1","title":"Hospice Item Set - Hospice Discharge Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-09-20T06:33:39.936Z","item":[{"linkId":"Section-36","text":"Section A: Administrative Information","type":"group","readOnly":true,"item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0"},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3"},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5"},{"linkId":"Section-36/A0270","prefix":"A0270","text":"Discharge Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.6"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1"}],"id":"item.0.item.7"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3"}],"id":"item.0.item.8"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1"}],"id":"item.0.item.9"},{"linkId":"Section-36/A2115","prefix":"A2115","text":"Reason for Discharge","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.10"}],"id":"item.0","description":"The section A on the form is for administrative information about the patient."},{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0","description":"The form asks for the patient's Medicaid Number. They should enter \"+\" if their Medicaid application is pending, or \"N\" if they are not a Medicaid recipient."},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1","description":"What is the patient's gender?"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2","description":"What is the patient's birth date?"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3","description":"The type of record pertaining to the patient needs to be identified."},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4","description":"The reason for the patient's assessment should be clearly specified."},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5","description":"What is the patient's admission date?"},{"linkId":"Section-36/A0270","prefix":"A0270","text":"Discharge Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.6","description":"What is the patient's discharge date?"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1"}],"id":"item.0.item.7","description":"The facility has designated provider numbers for the patient."},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0","description":"What is the patient's National Provider Identifier (NPI)?"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1","description":"The patient needs to provide their CMS Certification Number (CCN)."},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3"}],"id":"item.0.item.8","description":"What is the legal name of the patient or resident?"},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0","description":"What is the patient's first name?"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1","description":"What is the patient's middle initial?"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2","description":"What is the patient's last name?"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3","description":"What is the patient's suffix?"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1"}],"id":"item.0.item.9","description":"The patient needs to provide their Social Security and Medicare numbers."},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0","description":"What is the patient's Social Security Number?"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1","description":"What is the patient's Medicare number?"},{"linkId":"Section-36/A2115","prefix":"A2115","text":"Reason for Discharge","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.10","description":"What is the reason for the patient's discharge?"},{"linkId":"Section-47","text":"Section F: Preferences","type":"group","readOnly":true,"item":[{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR preference","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.1.item.0"}],"id":"item.1","description":"In section F of the form, the patient's preferences are to be indicated."},{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR preference","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.1.item.0","description":"What is the patient's preference regarding CPR?"},{"linkId":"Section-9","text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"}],"id":"item.2","description":"In Section I of the form, the active diagnoses of the patient are listed."},{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"The principal diagnosis for the patient is still undetermined."},{"linkId":"Section-10","text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J0100","prefix":"J0100","text":"Pain Management","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.3.item.0"}],"id":"item.3","description":"In Section J of the form, the patient is asked to provide information about their health conditions."},{"linkId":"Section-10/J0100","prefix":"J0100","text":"Pain Management","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.3.item.0","description":"Does the patient require pain management?"},{"linkId":"Section-14","text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/M2003","prefix":"M2003","text":"Medication follow-up","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.4.item.0"}],"id":"item.4","description":"In Section N of the form, it asks about the patient's medications."},{"linkId":"Section-14/M2003","prefix":"M2003","text":"Medication follow-up","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.4.item.0","description":"Does the patient require a medication follow-up?"},{"linkId":"Section-50","text":"Section O: Service Utilization","type":"group","readOnly":true,"item":[{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.0"},{"linkId":"Section-50/O5010","prefix":"O5010","text":"Number of hospice visits in final 3 days. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0"},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1"},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2"}],"id":"item.5.item.1"},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Registered Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.2"},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"Registered Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.3"},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"Registered Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.4"},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.5"},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.6"},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.7"},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"Medical Social Worker - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.8"},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"Medical Social Worker - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.9"},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"Medical Social Worker - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.10"},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Chaplain or Spiritual Counselor - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.11"},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Chaplain or Spiritual Counselor -Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.12"},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Chaplain or Spiritual Counselor - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.13"},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Licensed Professional Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.14"},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Licensed Professional Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.15"},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Licensed Professional Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.16"},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Aide - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.17"},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Aide - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.18"},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Aide - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.19"},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Level of care in final 7 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.20"},{"linkId":"Section-50/O5030","prefix":"O5030","text":"Number of hospice visits in 3 to 6 days prior to death. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3"}],"id":"item.5.item.21"},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"Registered Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.22"},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"Registered Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.23"},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"Registered Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.24"},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"Registered Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.25"},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.26"},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.27"},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.28"},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.29"},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Medical Social Worker - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.30"},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"Medical Social Worker - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.31"},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"Medical Social Worker - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.32"},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"Medical Social Worker - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.33"},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Chaplain or Spiritual Counselor - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.34"},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"Chaplain or Spiritual Counselor - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.35"},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"Chaplain or Spiritual Counselor - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.36"},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Chaplain or Spiritual Counselor - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.37"},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"Licensed Professional Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.38"},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"Licensed Professional Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.39"},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Licensed Professional Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.40"},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"Licensed Professional Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.41"},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Aide - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.42"},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"Aide - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.43"},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Aide - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.44"},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Aide - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.45"}],"id":"item.5","description":"In section O of the form, the patient's service utilization is assessed."},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.0","description":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final three days of their life?"},{"linkId":"Section-50/O5010","prefix":"O5010","text":"Number of hospice visits in final 3 days. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0"},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1"},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2"}],"id":"item.5.item.1","description":"The form requires the patient to enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated, specifically focusing on the final three days of hospice care."},{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0","description":"The number of hospice visits the patient had on the day of their death."},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1","description":"The form asked the patient how many hospice visits they had one day prior to their death."},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2","description":"How many hospice visits did the patient have two days prior to death?"},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Registered Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.2","description":"Did the registered nurse visit the patient on the day of death?"},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"Registered Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.3","description":"The registered nurse visited the patient one day prior to their death."},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"Registered Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.4","description":"Did the registered nurse visit the patient two days prior to their death?"},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.5","description":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant on the day of their death?"},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.6","description":"Did the patient have a visit from a physician, nurse practitioner, or physician assistant one day prior to their death?"},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.7","description":"Did the patient visit a physician, nurse practitioner, or physician assistant two days prior to their death?"},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"Medical Social Worker - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.8","description":"Did the medical social worker visit the patient on the day of their death?"},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"Medical Social Worker - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.9","description":"The medical social worker visited the patient one day prior to their death."},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"Medical Social Worker - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.10","description":"The medical social worker visited the patient two days prior to their death."},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Chaplain or Spiritual Counselor - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.11","description":"Did the patient receive a visit from a Chaplain or Spiritual Counselor on the day of their death?"},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Chaplain or Spiritual Counselor -Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.12","description":"Did the patient receive a visit from a chaplain or spiritual counselor one day prior to their death?"},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Chaplain or Spiritual Counselor - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.13","description":"Did the patient receive a visit from a chaplain or spiritual counselor two days prior to death?"},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Licensed Professional Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.14","description":"Did the Licensed Professional Nurse visit the patient on the day of their death?"},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Licensed Professional Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.15","description":"Did the licensed professional nurse visit the patient one day prior to their death?"},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Licensed Professional Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.16","description":"The patient was visited by a Licensed Professional Nurse two days prior to their death."},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Aide - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.17","description":"Did the aide visit the patient on the day of death?"},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Aide - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.18","description":"Did the aide visit the patient one day prior to their death?"},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Aide - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.19","description":"Did the patient receive an aide visit two days prior to death?"},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Level of care in final 7 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.20","description":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final seven days of their life?"},{"linkId":"Section-50/O5030","prefix":"O5030","text":"Number of hospice visits in 3 to 6 days prior to death. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3"}],"id":"item.5.item.21","description":"The form is asking for the number of visits the patient received from hospice staff in the 3 to 6 days prior to their death. The respondent should enter the number of visits provided by hospice staff from the indicated discipline, on each of the specified dates."},{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0","description":"How many hospice visits did the patient have three days prior to death?"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1","description":"How many hospice visits did the patient have four days prior to death in the period of 3 to 6 days before death?"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2","description":"How many hospice visits did the patient have five days prior to death?"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3","description":"How many hospice visits did the patient have in the six days prior to their death?"},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"Registered Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.22","description":"The patient was visited by a registered nurse three days prior to their death."},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"Registered Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.23","description":"The registered nurse visited the patient four days prior to their death."},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"Registered Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.24","description":"The registered nurse visited the patient five days prior to their death."},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"Registered Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.25","description":"The registered nurse visited the patient six days prior to their death."},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.26","description":"Did the patient visit a physician, nurse practitioner, or physician assistant three days prior to death?"},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.27","description":"The patient visited the physician, nurse practitioner, or physician assistant four days prior to their death."},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.28","description":"Did the patient visit a physician, nurse practitioner, or physician assistant five days prior to their death?"},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.29","description":"The patient was visited by a physician, nurse practitioner, or physician assistant six days prior to death."},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Medical Social Worker - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.30","description":"The medical social worker visited the patient three days prior to their death."},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"Medical Social Worker - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.31","description":"The medical social worker visited the patient four days prior to their death."},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"Medical Social Worker - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.32","description":"The medical social worker visited the patient five days prior to their death."},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"Medical Social Worker - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.33","description":"The medical social worker visited the patient six days prior to their death."},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Chaplain or Spiritual Counselor - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.34","description":"Did the patient receive a visit from a chaplain or spiritual counselor three days prior to death?"},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"Chaplain or Spiritual Counselor - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.35","description":"Did the patient receive a visit from a chaplain or spiritual counselor four days prior to death?"},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"Chaplain or Spiritual Counselor - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.36","description":"Did the patient receive visits from a chaplain or spiritual counselor five days prior to death?"},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Chaplain or Spiritual Counselor - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.37","description":"Did the patient receive a visit from a chaplain or spiritual counselor six days prior to death?"},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"Licensed Professional Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.38","description":"The licensed professional nurse visited the patient three days prior to their death."},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"Licensed Professional Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.39","description":"The Licensed Professional Nurse visited the patient four days prior to their death."},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Licensed Professional Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.40","description":"The patient was visited by a licensed professional nurse five days prior to their death."},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"Licensed Professional Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.41","description":"The Licensed Professional Nurse visited the patient six days prior to their death."},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Aide - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.42","description":"The patient had visits from an aide three days prior to their death."},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"Aide - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.43","description":"Did the aide visit the patient four days prior to death?"},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Aide - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.44","description":"Did the patient receive aid visits five days prior to death?"},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Aide - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.45","description":"Did the aide visit the patient six days prior to death?"},{"linkId":"Section-48","text":"Section Z: Record Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0"},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1"}],"id":"item.6","description":"In Section Z, the record administration pertaining to the patient needs to be filled out."},{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0","description":"The signature of the person who completed the patient's assessment is required."},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0","description":"The patient needs to provide their signature, title, and the date on which they completed section A."},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1","description":"The patient is required to provide their signature and title, and then complete section B, after which they must record the date the section was completed."},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2","description":"The patient should provide their signature, title, and date in the section marked 'C'."},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3","description":"The patient was required to provide their signature and title, fill out several sections, and note down the date they completed section D."},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4","description":"\"The patient is required to provide a signature, title, and complete various sections. They also need to provide the date on which the section E was completed.\""},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5","description":"The patient completed the sections of the form and signed it, indicating their title and date when they finished section F."},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6","description":"The patient needs to provide their signature, title, and the date the sections were completed in Section G."},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7","description":"The patient needs to provide their signature, title, and the date on which the form section H was completed."},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8","description":"The patient is required to provide their signature, title, the sections they have completed, and the date on which the section was completed."},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9","description":"The patient's form includes their signature, title, date, and the sections they completed, specifically section J."},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10","description":"The patient is required to provide their signature, title, and the date on which the sections were completed."},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11","description":"The form for the patient includes sections for a signature, title, and the date when the section was completed."},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1","description":"The signature of the RN Coordinator is required to verify the completion of the patient's assessment."},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0","description":"The form requires the patient's signature."},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1","description":"The date when the Registered Nurse Assessment Coordinator signed the patient's assessment as complete."},null],"_id":"naPn4JNtboXifDjvX"} {"responseType":"QuestionnaireResponse","questionnaire":"IRF-PAI-IA-3.0","id":"IRF-PAI-IA-3.0-1","title":"Inpatient Rehabilitation Facility Patient Assessment Instrument - IRF Admission","description":"Assessment data collected on all Medicare Part A fee-for-service patients who receive services under Part A from an inpatient rehabilitation facility (IRF) at admission and upon discharge.","status":"draft","authored":"2024-09-20T06:34:32.500Z","item":[{"linkId":"Section-45","text":"Discharge Information","type":"group","readOnly":true,"item":[{"linkId":"Section-45/40","prefix":"40","text":"Discharge date","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.0"}],"id":"item.0","description":"The patient's discharge information is ready to be reviewed."},{"linkId":"Section-45/40","prefix":"40","text":"Discharge date","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.0","description":"What is the patient's discharge date?"},{"linkId":"Section-38","code":[{"system":"http://loinc.org","code":"85395-2","display":"IRF-PAI v3.0 - Identification information [CMS Assessment]"}],"text":"Identification Information","type":"group","readOnly":true,"item":[{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.0"},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.1"},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.1.item.2"},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.1.item.3"},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.4"},{"linkId":"Section-38/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.1.item.5"},{"linkId":"Section-38/A0800","prefix":"A0800","text":"Gender","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}],"id":"item.1.item.6"},{"linkId":"Section-38/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.7"},{"linkId":"Section-38/A1200","prefix":"A1200","text":"Marital Status","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}],"id":"item.1.item.8"},{"linkId":"Section-38/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.9"},{"linkId":"Section-38/11","prefix":"11","text":"Zip Code of {Patient's/Resident's} Pre-Hospital Residence","type":"text","repeats":false,"readOnly":false,"maxLength":5,"id":"item.1.item.10"},{"linkId":"Section-38/13","prefix":"13","text":"Assessment Reference Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.11"},{"linkId":"Section-38/14","prefix":"14","text":"Admission Class","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27331-0","display":"Initial rehab"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27332-8","display":"Evaluation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4395-5","display":"Readmission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27335-1","display":"Continuing rehabilitation"}}],"id":"item.1.item.12"},{"linkId":"Section-38/17","prefix":"17","text":"Pre-hospital Living With (Code only if item {Pre-hospital Living Setting} is Home)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27350-0","display":"Alone"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27351-8","display":"Family/Relatives"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27352-6","display":"Friends"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27353-4","display":"Attendant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}],"id":"item.1.item.13"},{"linkId":"Section-38/15A","prefix":"15A","text":"Admit From","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.14"},{"linkId":"Section-38/16A","prefix":"16A","text":"Pre-hospital Living Setting. Use codes from {Admit From}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.15"},{"linkId":"Section-38/1","prefix":"1","text":"{Facility/Provider} Information","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0"}],"id":"item.1.item.16"},{"linkId":"Section-38/5B","prefix":"5B","text":"{Patient/Resident} Identification Number","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.17"},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}],"id":"item.1.item.18"}],"id":"item.1","description":"The form requires the patient's identification information."},{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.0","description":"What is the patient's CMS Certification Number (CCN)?"},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.1","description":"What is the patient's first name?"},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.1.item.2","description":"What is the patient's last name?"},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.1.item.3","description":"What is the patient's Social Security Number?"},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.4","description":"What is the patient's Medicare number?"},{"linkId":"Section-38/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.1.item.5","description":"The patient should enter a \"+\" in the section labeled \"Medicaid Number\" if their Medicaid application is pending, or a \"N\" if they are not a Medicaid recipient."},{"linkId":"Section-38/A0800","prefix":"A0800","text":"Gender","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}],"id":"item.1.item.6","description":"What is the patient's gender? The options are male, female, or other."},{"linkId":"Section-38/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.7","description":"What is the patient's birth date?"},{"linkId":"Section-38/A1200","prefix":"A1200","text":"Marital Status","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}],"id":"item.1.item.8","description":"What is the patient's marital status? Is they married, single, divorced, or widowed?"},{"linkId":"Section-38/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.9","description":"The admission date of the patient is when they were admitted to the hospital."},{"linkId":"Section-38/11","prefix":"11","text":"Zip Code of {Patient's/Resident's} Pre-Hospital Residence","type":"text","repeats":false,"readOnly":false,"maxLength":5,"id":"item.1.item.10","description":"What is the zip code of the patient's pre-hospital residence?"},{"linkId":"Section-38/13","prefix":"13","text":"Assessment Reference Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.11","description":"The assessment reference date for the patient has been set."},{"linkId":"Section-38/14","prefix":"14","text":"Admission Class","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27331-0","display":"Initial rehab"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27332-8","display":"Evaluation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4395-5","display":"Readmission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27335-1","display":"Continuing rehabilitation"}}],"id":"item.1.item.12","description":"The admission class for the patient is being determined."},{"linkId":"Section-38/17","prefix":"17","text":"Pre-hospital Living With (Code only if item {Pre-hospital Living Setting} is Home)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Alone"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27350-0","display":"Alone"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Family / Relatives"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27351-8","display":"Family/Relatives"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Friends"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27352-6","display":"Friends"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Attendant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27353-4","display":"Attendant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Other"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}],"id":"item.1.item.13","description":"The patient's pre-hospital living situation should be coded only if the patient was living at home before hospitalization."},{"linkId":"Section-38/15A","prefix":"15A","text":"Admit From","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.14","description":"From where was the patient admitted?"},{"linkId":"Section-38/16A","prefix":"16A","text":"Pre-hospital Living Setting. Use codes from {Admit From}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.15","description":"The pre-hospital living setting of the patient is determined by using codes from the 'Admit From' category."},{"linkId":"Section-38/1","prefix":"1","text":"{Facility/Provider} Information","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0"}],"id":"item.1.item.16","description":"The form contains a section for the patient to provide information about the facility or provider they are connected with.\n"},{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0","description":"What is the name of the facility or provider for the patient?"},{"linkId":"Section-38/5B","prefix":"5B","text":"{Patient/Resident} Identification Number","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.17","description":"What is the patient's or resident's identification number?"},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}],"id":"item.1.item.18","description":"The patient should check all the boxes that apply to their race or ethnicity."},{"linkId":"Section-41","code":[{"system":"http://loinc.org","code":"87415-6","display":"IRF-PAI v3.0 - Medical Info [CMS Assessment]"}],"text":"Medical Information","type":"group","readOnly":true,"item":[{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Height (in inches). Record most recent height measure since {admission}","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"Weight (in pounds). Base weight on most recent measure in last {specify time period in days}; measure weight consistently, according to standard {facility/setting} practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer","repeats":false,"readOnly":false,"maxLength":3,"id":"item.2.item.1"},{"linkId":"Section-41/21A","prefix":"21A","text":"Impairment Group - Admission: Condition requiring admission to rehabilitation; code according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.2.item.2"},{"linkId":"Section-41/23","prefix":"23","text":"Date of Onset of Impairment","type":"open-choice","repeats":false,"readOnly":false,"id":"item.2.item.3"},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Are there any arthritis conditions recorded in items {impairment group, etiologic diagnosis, or comorbid conditions} that meet all the regulatory requirements for {IRF} classification","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.2.item.4"},{"linkId":"Section-41/22","prefix":"22","text":"Etiologic Diagnosis: (Use ICD codes to indicate the etiologic problem that led to the condition for which the {patient/resident} is receiving rehabilitation)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0"},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1"},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2"}],"id":"item.2.item.5"},{"linkId":"Section-41/24","prefix":"24","text":"Comorbid Conditions. Use ICD codes to enter comorbid medical conditions","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8"},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18"},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21"},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24"}],"id":"item.2.item.6"},{"linkId":"Section-41/21","prefix":"21","text":"Impairment group","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0"}],"id":"item.2.item.7"}],"id":"item.2","description":"The form is requesting the patient's medical information."},{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Height (in inches). Record most recent height measure since {admission}","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"The form asks for the patient's height in inches and requests the most recent measurement since their admission."},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"Weight (in pounds). Base weight on most recent measure in last {specify time period in days}; measure weight consistently, according to standard {facility/setting} practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer","repeats":false,"readOnly":false,"maxLength":3,"id":"item.2.item.1","description":"The patient's weight, in pounds, should be based on the most recent measurement taken within the specified time period in days. It's important to measure the patient's weight consistently, adhering to the standard practice of the facility or setting. For instance, this could be done in the morning after voiding, before a meal, with shoes off, and so on."},{"linkId":"Section-41/21A","prefix":"21A","text":"Impairment Group - Admission: Condition requiring admission to rehabilitation; code according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.2.item.2","description":"The impairment group on the admission form refers to the condition that required the patient's admission to rehabilitation, which should be coded according to Appendix A."},{"linkId":"Section-41/23","prefix":"23","text":"Date of Onset of Impairment","type":"open-choice","repeats":false,"readOnly":false,"id":"item.2.item.3","description":"When did the patient's impairment begin?"},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Are there any arthritis conditions recorded in items {impairment group, etiologic diagnosis, or comorbid conditions} that meet all the regulatory requirements for {IRF} classification","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.2.item.4","description":"Does the patient have any arthritis conditions recorded in the impairment group, etiologic diagnosis, or comorbid conditions that meet all the regulatory requirements for Inpatient Rehabilitation Facility (IRF) classification?"},{"linkId":"Section-41/22","prefix":"22","text":"Etiologic Diagnosis: (Use ICD codes to indicate the etiologic problem that led to the condition for which the {patient/resident} is receiving rehabilitation)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0"},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1"},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2"}],"id":"item.2.item.5","description":"The etiologic diagnosis requires the use of ICD codes to indicate the underlying problem that led to the condition for which the patient is receiving rehabilitation."},{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0","description":"The form for the patient includes a section labeled \"Etiologic Diagnosis A\"."},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1","description":"The form for the patient includes a section labeled \"Etiologic Diagnosis B\"."},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2","description":"The form asks for the patient's etiologic diagnosis C."},{"linkId":"Section-41/24","prefix":"24","text":"Comorbid Conditions. Use ICD codes to enter comorbid medical conditions","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8"},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18"},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21"},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24"}],"id":"item.2.item.6","description":"The patient is instructed to use ICD codes to enter their comorbid medical conditions under the section labeled \"Comorbid Conditions.\""},{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0","description":"Does the patient have a comorbid condition A?"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1","description":"Does the patient have Comorbid Condition B?"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2","description":"Does the patient have Comorbid Condition C?"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3","description":"Does the patient have any comorbid condition D?"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4","description":"Does the patient have a comorbid condition E?"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5","description":"Does the patient have a comorbid condition F?"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6","description":"Does the patient have comorbid condition G?"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7","description":"Does the patient have a comorbid condition H?"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8","description":"Does the patient have a comorbid condition? If yes, please specify."},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9","description":"Does the patient have Comorbid Condition J?"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10","description":"Does the patient have a comorbid condition K?"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11","description":"Does the patient have any comorbid condition L?"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12","description":"Does the patient have a comorbid condition M?"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13","description":"Does the patient have a comorbid condition N?"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14","description":"Does the patient have any comorbid conditions?"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15","description":"Does the patient have a comorbid condition P?"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16","description":"Does the patient have a comorbid condition?"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17","description":"Does the patient have a comorbid condition R?"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18","description":"The form asks if the patient has any comorbid conditions."},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19","description":"Does the patient have a comorbid condition T?"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20","description":"Does the patient have a comorbid condition U?"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21","description":"Does the patient have a comorbid condition V? Please indicate yes or no."},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22","description":"Does the patient have any comorbid condition W?"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23","description":"Does the patient have a comorbid condition X?"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24","description":"Does the patient have comorbid condition Y?"},{"linkId":"Section-41/21","prefix":"21","text":"Impairment group","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0"}],"id":"item.2.item.7","description":"What is the patient's impairment group?"},{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0","description":"What is the impairment group upon admission for the patient?"},{"linkId":"Section-40","code":[{"system":"http://loinc.org","code":"85401-8","display":"IRF-PAI - Payer information [CMS Assessment]"}],"text":"Payer Information","type":"group","readOnly":true,"item":[{"linkId":"Section-40/20","prefix":"20","text":"Payment Source","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0"},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1"}],"id":"item.3.item.0"}],"id":"item.3","description":"The form requires the patient's payer information."},{"linkId":"Section-40/20","prefix":"20","text":"Payment Source","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0"},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1"}],"id":"item.3.item.0","description":"The payment source for the patient is being determined."},{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0","description":"The primary source of information regarding the patient's health condition is the patient themselves."},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1","description":"The form for the patient includes a section titled \"Secondary Source.\""},{"linkId":"Section-2","code":[{"system":"http://loinc.org","code":"88522-8","display":"IRF-PAI v2.0 - Hearing, speech, and vision - admission [CMS Assessment]"}],"text":"Section B: Hearing, Speech, and Vision","type":"group","readOnly":true,"item":[{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}],"id":"item.4.item.0"},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}],"id":"item.4.item.1"}],"id":"item.4","description":"In Section B of the form, the patient's hearing, speech, and vision capabilities are assessed."},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}],"id":"item.4.item.0","description":"The patient's expression of ideas and wants, considering both verbal and non-verbal expression and excluding language barriers, should be evaluated. Does the patient often communicate their ideas and desires clearly? The answer could be 'Always', 'Often', 'Sometimes', 'Rarely', or 'Never'."},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}],"id":"item.4.item.1","description":"Does the patient understand both verbal and non-verbal content with the use of a hearing aid or device, if used, while excluding any language barriers?"},{"linkId":"Section-3","code":[{"system":"http://loinc.org","code":"88524-4","display":"IRF-PAI v2.0 - Cognitive patterns - admission [CMS Assessment]"}],"text":"Section C: Cognitive Patterns","type":"group","readOnly":true,"item":[{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all {patients/residents}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.5.item.0"},{"linkId":"Section-3/C0200","prefix":"C0200","text":"Repetition of Three Words - Ask {patient/resident}: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}],"id":"item.5.item.1"},{"linkId":"Section-3/C0500","prefix":"C0500","text":"BIMS Summary Score. Add scores for {Brief Interview for Mental Status questions} and fill in total score (00-15). Enter 99 if the {patient/resident} was unable to complete the interview","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.2"},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the Staff Assessment for Mental Status be Conducted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes ({patient/resident} was unable to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}],"id":"item.5.item.3"},{"linkId":"Section-3/C0300","prefix":"C0300","text":"BIMS: Temporal Orientation (orientation to year, month, and day)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0"},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1"},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2"}],"id":"item.5.item.4"},{"linkId":"Section-3/C0400","prefix":"C0400","text":"Recall. Ask {patient/resident}: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0"},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1"},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2"}],"id":"item.5.item.5"},{"linkId":"Section-3/C0900","prefix":"C0900","text":"Memory/Recall Ability: Check all that the {patient/resident} was normally able to recall","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above were recalled"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}],"id":"item.5.item.6"}],"id":"item.5","description":"In Section C of the form, the patient's cognitive patterns are assessed."},{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all {patients/residents}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.5.item.0","description":"Should a Brief Interview for Mental Status be conducted? It is suggested to attempt to conduct the interview with all patients or residents."},{"linkId":"Section-3/C0200","prefix":"C0200","text":"Repetition of Three Words - Ask {patient/resident}: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}],"id":"item.5.item.1","description":"The form asks the patient, \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" The number of words repeated after the first attempt is then recorded by the medical professional."},{"linkId":"Section-3/C0500","prefix":"C0500","text":"BIMS Summary Score. Add scores for {Brief Interview for Mental Status questions} and fill in total score (00-15). Enter 99 if the {patient/resident} was unable to complete the interview","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.2","description":"The BIMS Summary Score should be calculated by adding the scores for the Brief Interview for Mental Status questions and filling in the total score, which ranges from 00 to 15. If the patient or resident was unable to complete the interview, the score to be entered should be 99."},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the Staff Assessment for Mental Status be Conducted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes ({patient/resident} was unable to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}],"id":"item.5.item.3","description":"Should the staff assessment for the patient's mental status be conducted?"},{"linkId":"Section-3/C0300","prefix":"C0300","text":"BIMS: Temporal Orientation (orientation to year, month, and day)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0"},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1"},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2"}],"id":"item.5.item.4","description":"The patient's BIMS assessment includes a temporal orientation evaluation, which evaluates their orientation to the current year, month, and day."},{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0","description":"The form asks the patient or resident, \"Please tell me what year it is right now.\" They are able to report the correct year."},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1","description":"The form asks the patient or resident, \"What month are we in right now?\" The patient or resident should be able to report the correct month."},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2","description":"Ask the patient or resident: \"What day of the week is today?\" They should be able to report the correct day of the week."},{"linkId":"Section-3/C0400","prefix":"C0400","text":"Recall. Ask {patient/resident}: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0"},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1"},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2"}],"id":"item.5.item.5","description":"The doctor asks the patient, \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If the patient is unable to remember a word, the doctor gives a cue, such as 'something to wear', 'a color', or 'a piece of furniture', for that particular word."},{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0","description":"The patient is able to recall the word \"sock\"."},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1","description":"The patient is able to recall the color \"blue\"."},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2","description":"Is the patient able to recall \"bed\"?"},{"linkId":"Section-3/C0900","prefix":"C0900","text":"Memory/Recall Ability: Check all that the {patient/resident} was normally able to recall","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above were recalled"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}],"id":"item.5.item.6","description":"The patient's or resident's ability to recall normally should be assessed. Please check all that apply."},{"linkId":"Section-37","code":[{"system":"http://loinc.org","code":"88482-5","display":"Functional abilities and goals - admission [CMS Assessment]"}],"text":"Section GG: Functional Abilities and Goals","type":"group","readOnly":true,"item":[{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.0"},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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If managing an ostomy, include wiping the opening but not managing equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.13"},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.14"},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.28"},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the {patient/resident} use a wheelchair and/or scooter? - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.6.item.29"},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.30"},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.31"},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.32"},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.33"},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.34"},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.35"},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.36"},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.37"},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.45"},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.46"},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.47"},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.48"},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"4 steps: The ability to go up and down four steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.49"},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.50"},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.51"},{"linkId":"Section-37/GG0100","prefix":"GG0100","text":"Prior Functioning: Everyday Activities. Indicate the {patient's/resident's} usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0"},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1"},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2"},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3"}],"id":"item.6.item.52"},{"linkId":"Section-37/GG0130","prefix":"GG0130","text":"Self-Care.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0"},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1"}],"id":"item.6.item.53"},{"linkId":"Section-37/GG0170","prefix":"GG0170","text":"Mobility.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0"},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1"}],"id":"item.6.item.54"},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Prior Device Use. Indicate devices and aids used by the {patient/resident} prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.6.item.55"}],"id":"item.6","description":"In Section GG of the form, the patient's functional abilities and goals are documented."},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.0","description":"The question for the patient or resident is about their eating ability. Specifically, can they use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them? This is in reference to their performance upon admission."},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.1","description":"The form asks about the patient's oral hygiene, specifically their ability to use suitable items to clean their teeth. It also inquires if they have dentures and if so, their ability to insert and remove them from the mouth, as well as manage denture soaking and rinsing with the use of equipment. This is relevant to their admission performance."},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.2","description":"The form asks about the patient's ability to maintain perineal hygiene and adjust their clothes before and after voiding or having a bowel movement. If the patient is managing an ostomy, it includes the task of wiping the opening but not managing the equipment. This is pertaining to their performance upon admission."},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.3","description":"The discharge goal for the patient is to have the ability to use suitable utensils in order to bring food and/or liquid to their mouth and to be able to swallow food and/or liquid once the meal is placed before them."},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.4","description":"The form inquires about the patient's oral hygiene: their ability to use suitable items to clean their teeth. It also asks if the patient has dentures and if so, it assesses their ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with the use of equipment. The goal is to prepare the patient for discharge."},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.5","description":"The discharge goal for the patient is related to toileting hygiene, which refers to their ability to maintain perineal hygiene, adjust clothing before and after voiding or having a bowel movement. If they are managing an ostomy, this also includes wiping the opening, but not managing the equipment."},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.6","description":"The form asks about the patient's ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed, as part of their admission performance."},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.7","description":"The form asks about the patient's admission performance regarding their ability to move from sitting on the side of the bed to lying flat on the bed."},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.8","description":"The form is asking about the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. This is in reference to their admission performance."},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.9","description":"The discharge goal for the patient is to acquire the ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed."},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.10","description":"The discharge goal for the patient is to have the ability to move from sitting on the side of the bed to lying flat on the bed."},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.11","description":"The discharge goal for the patient is to have the ability to move from lying on their back to sitting on the side of the bed without any back support."},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.12","description":"The form asks the patient about their ability to come to a standing position from sitting in a chair, a wheelchair, or on the side of the bed, and requests them to rate their admission performance."},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.13","description":"The form is asking about the patient's ability to transfer to and from a bed to a chair or wheelchair. It is inquiring about their admission performance."},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.14","description":"The form asks about the patient's ability to transfer to and from a toilet or commode on their own as it pertains to their performance upon admission."},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.15","description":"The question on the form asks about the patient's admission performance in relation to their ability to walk. Specifically, it inquires whether, once standing, the patient can walk at least 10 feet in a room, corridor, or similar space."},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.16","description":"Once standing, the patient has the ability to walk at least 50 feet and make two turns as part of their admission performance."},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.17","description":"The form inquires about the patient's capability to walk at least 150 feet in a corridor or similar space once they are standing. This is referred to as the \"Admission Performance\" aspect."},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.18","description":"Once the patient is seated in the wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. This is a requirement for admission performance."},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.19","description":"The admission performance form includes a question regarding the patient's ability, once seated in a wheelchair or scooter, to wheel at least 150 feet in a corridor or similar space."},{"linkId":"Section-37/GG0170K3","prefix":"GG0170K3","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Discharge Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.20","description":"The form asks about the patient's ability to walk at least 150 feet in a corridor or similar space once they are standing, with the label of \"Discharge Performance\"."},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.21","description":"The discharge goal for the patient is to develop the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed."},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.22","description":"The form asks about the patient's ability to transfer themselves to and from a bed to a chair or wheelchair. The discharge goal is to evaluate this capability."},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.23","description":"The discharge goal for the patient refers to their ability to independently get on and off a toilet or commode."},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.24","description":"The question on the form is asking about the patient's ability, once standing, to walk at least 10 feet in a room, corridor, or similar space. The goal is that the patient should be able to do this upon discharge."},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.25","description":"The label is asking about the patient's ability, once standing, to walk a minimum of 50 feet and make two turns. The goal is to achieve this by the time of discharge."},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.26","description":"The form asks if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The response options for this question are 'discharge goal'."},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.27","description":"The discharge goal for the patient is to be able to wheel at least 50 feet and make two turns once seated in a wheelchair or scooter."},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.28","description":"The discharge goal for the patient is to gain the ability to wheel at least 150 feet in a corridor or similar space once seated in a wheelchair or scooter."},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the {patient/resident} use a wheelchair and/or scooter? - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.6.item.29","description":"Does the patient or resident use a wheelchair and/or scooter upon admission?"},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.30","description":"The form is asking the patient to indicate the type of wheelchair or scooter they use upon admission."},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.31","description":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission."},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.32","description":"The form asks about the patient's ability to shower or bathe themselves, which includes tasks such as washing, rinsing, and drying themselves, but does not include washing their back and hair, nor transferring in and out of the tub or shower. The question relates to their performance upon admission."},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.33","description":"The admission form inquires about the patient's ability to dress and undress above the waist, including handling fasteners if applicable, in the section labeled \"Upper body dressing.\""},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.34","description":"On the admission performance form, there is a question about the patient's ability to dress and undress below the waist, including handling fasteners. This does not include dealing with footwear."},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.35","description":"Does the patient have the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable? Please evaluate their performance upon admission."},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.36","description":"On the admission form, it asks about the patient's ability to transfer in and out of a car or van on the passenger side, without including the ability to open or close the door or fasten the seat belt."},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.37","description":"The form asks if the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, either indoors or outdoors. This is in reference to their admission performance."},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.38","description":"The form asks about the patient's ability to go up and down a curb and/or up and down one step in regards to their admission performance."},{"linkId":"Section-37/GG0170N1","prefix":"GG0170N1","text":"4 steps: The ability to go up and down four steps with or without a rail. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.39","description":"The form asks about the patient's ability to go up and down four steps with or without a rail in terms of admission performance."},{"linkId":"Section-37/GG0170O1","prefix":"GG0170O1","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.40","description":"The form asks whether the patient has the ability to go up and down 12 steps with or without a rail as part of their admission performance."},{"linkId":"Section-37/GG0170P1","prefix":"GG0170P1","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.41","description":"The form asks about the patient's admission performance in terms of their ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor."},{"linkId":"Section-37/GG0130E2","prefix":"GG0130E2","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.42","description":"The discharge goal for the patient is to be able to shower or bathe themselves. This means the patient should have the ability to wash, rinse, and dry themselves, excluding washing of the back and hair. It does not include transferring in or out of the tub or shower."},{"linkId":"Section-37/GG0130F2","prefix":"GG0130F2","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.43","description":"The discharge goal for the patient is to be able to dress and undress above the waist, which includes handling any fasteners, if applicable, on their own."},{"linkId":"Section-37/GG0130G2","prefix":"GG0130G2","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.44","description":"The discharge goal for the patient is to be able to independently dress and undress their lower body, below the waist, including handling fasteners, but not including footwear."},{"linkId":"Section-37/GG0130H2","prefix":"GG0130H2","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.45","description":"The form asks about the patient's ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable, and what the discharge goal for this ability is."},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.46","description":"The discharge goal for the patient is to have the ability to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten their seat belt."},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.47","description":"The form asks if the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoor or outdoor, with the discharge goal being the endpoint."},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.48","description":"The question on the form asks about the patient's ability to go up and down a curb and/or up and down one step. The label for this section is \"Discharge Goal\"."},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"4 steps: The ability to go up and down four steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.49","description":"The discharge goal for the patient is to have the ability to go up and down four steps with or without a rail."},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.50","description":"The discharge goal for the patient is to develop the ability to go up and down 12 steps with or without the use of a rail."},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.51","description":"The discharge goal for the patient is to have the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor."},{"linkId":"Section-37/GG0100","prefix":"GG0100","text":"Prior Functioning: Everyday Activities. Indicate the {patient's/resident's} usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0"},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1"},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2"},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3"}],"id":"item.6.item.52","description":"Please indicate the patient's usual ability with everyday activities prior to their current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0","description":"Please code the patient's or resident's need for assistance with bathing, dressing, using the toilet, and eating prior to their current illness, exacerbation, or injury for the Self-Care section."},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1","description":"The form requests the code for the patient's or resident's need for assistance with walking from room to room, with or without a device such as a cane, crutch, or walker, prior to the current illness, exacerbation, or injury to determine their level of indoor mobility and ambulation."},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2","description":"The form asks to code the patient's or resident's need for assistance with internal or external stairs, with or without a device such as a cane, crutch, or walker, prior to the current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3","description":"The form asks to code the patient's or resident's need for assistance with planning regular tasks, such as shopping or remembering to take medication, prior to their current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0130","prefix":"GG0130","text":"Self-Care.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0"},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1"}],"id":"item.6.item.53","description":"The patient is capable of self-care."},{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0","description":"For the category of Self-Care, please code the patient's usual performance at the time of admission for each activity using the 6-point scale. If the activity was not attempted at the time of admission, please code the reason."},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1","description":"Please code the patient's or resident's self-care discharge goals using the 6-point scale. The use of codes 07, 09, 10, or 88 is permissible to code the discharge goals."},{"linkId":"Section-37/GG0170","prefix":"GG0170","text":"Mobility.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0"},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1"}],"id":"item.6.item.54","description":"The patient's mobility status is being assessed."},{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0","description":"For the section on mobility, please code the patient's or resident's usual performance at the time of admission for each activity using the 6-point scale. If a certain activity was not attempted at the time of admission, code the reason."},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1","description":"The form instructs the user to code the patient's or resident's discharge goals using the 6-point scale. The use of codes 07, 09, 10, or 88 is permissible to code the discharge goals."},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Prior Device Use. Indicate devices and aids used by the {patient/resident} prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.6.item.55","description":"Please indicate the devices and aids that the patient or resident used prior to their current illness, exacerbation, or injury. Check all that apply."},{"linkId":"Section-8","code":[{"system":"http://loinc.org","code":"83237-8","display":"Bladder and bowel [CMS Assessment]"}],"text":"Section H: Bladder and Bowel","type":"group","readOnly":true,"item":[{"linkId":"Section-8/H0400","prefix":"H0400","text":"Bowel Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}],"id":"item.7.item.0"},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Bladder Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}],"id":"item.7.item.1"}],"id":"item.7","description":"In section H of the form, the patient's bladder and bowel conditions are addressed."},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Bowel Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}],"id":"item.7.item.0","description":"Please select the one category that best describes the bowel continence of the patient or resident."},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Bladder Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}],"id":"item.7.item.1","description":"Please select the one category that best describes the patient's or resident's bladder continence."},{"linkId":"Section-9","code":[{"system":"http://loinc.org","code":"83264-2","display":"IRF-PAI - Active diagnoses [CMS Assessment]"}],"text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0000","prefix":"I0000","text":"Active Diagnoses in the last 7 days: Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.8.item.0"}],"id":"item.8","description":"In Section I of the form, the patient's active diagnoses are listed."},{"linkId":"Section-9/I0000","prefix":"I0000","text":"Active Diagnoses in the last 7 days: Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.8.item.0","description":"The patient has been asked to indicate all of their active diagnoses from the last 7 days on the form. They should check all that apply. The diagnoses provided in parentheses are just examples and should not be considered as an all-inclusive list."},{"linkId":"Section-10","code":[{"system":"http://loinc.org","code":"83273-3","display":"IRF-PAI - Health conditions - admission [CMS Assessment]"}],"text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J1750","prefix":"J1750","text":"History of Falls: Has the {patient/resident} had two or more falls in the past year or any fall with injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.0"},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Prior Surgery. Did the {patient/resident} have major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.1"}],"id":"item.9","description":"In Section J of the form, the patient's health conditions are being evaluated."},{"linkId":"Section-10/J1750","prefix":"J1750","text":"History of Falls: Has the {patient/resident} had two or more falls in the past year or any fall with injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.0","description":"Does the patient or resident have a history of having two or more falls in the past year, or any fall that resulted in injury in the past year?"},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Prior Surgery. Did the {patient/resident} have major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.1","description":"Did the patient or resident have any major surgery during the 100 days prior to their admission?"},{"linkId":"Section-11","code":[{"system":"http://loinc.org","code":"83244-4","display":"IRF-PAI v2.0 - Swallowing/nutritional status - admission [CMS Assessment]"}],"text":"Section K: Swallowing/Nutritional Status","type":"group","readOnly":true,"item":[{"linkId":"Section-11/K0110","prefix":"K0110","text":"Swallowing/Nutritional Status. Indicate the {patient's/resident's} usual ability to swallow: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Regular food - Solids and liquids swallowed safely without supervision or modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Modified food consistency/supervision - {Patient/Resident} requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Tube/parenteral feeding - Tube/parenteral feeding used wholly or partially as a means of sustenance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}],"id":"item.10.item.0"}],"id":"item.10","description":"In Section K of the form, the patient's swallowing and nutritional status is assessed."},{"linkId":"Section-11/K0110","prefix":"K0110","text":"Swallowing/Nutritional Status. Indicate the {patient's/resident's} usual ability to swallow: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Regular food - Solids and liquids swallowed safely without supervision or modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Modified food consistency/supervision - {Patient/Resident} requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Tube/parenteral feeding - Tube/parenteral feeding used wholly or partially as a means of sustenance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}],"id":"item.10.item.0","description":"Please indicate the patient's usual ability to swallow regarding their swallowing or nutritional status. Check all that apply."},{"linkId":"Section-13","code":[{"system":"http://loinc.org","code":"85055-2","display":"IRF-PAI v3.0, LCDS v4.00 - Skin conditions - admission [CMS Assessment]"}],"text":"Section M: Skin Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-13/M0210","prefix":"M0210","text":"Unhealed Pressure Ulcers/Injuries. Does this {patient/resident} have one or more unhealed pressure ulcers/injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.11.item.0"},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"Number of Stage 2 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.1"},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"Number of Stage 3 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.2"},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"Number of Stage 4 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.3"},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.4"},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.5"},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.6"},{"linkId":"Section-13/M0300","prefix":"M0300","text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0"},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1"},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2"},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3"},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4"},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5"},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6"}],"id":"item.11.item.7"},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"Number of Stage 1 pressure injuries","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.8"}],"id":"item.11","description":"In Section M of the form, the patient's skin conditions are addressed."},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Unhealed Pressure Ulcers/Injuries. Does this {patient/resident} have one or more unhealed pressure ulcers/injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.11.item.0","description":"Does this patient or resident have one or more unhealed pressure ulcers or injuries?"},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"Number of Stage 2 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.1","description":"The patient has how many Stage 2 pressure ulcers?"},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"Number of Stage 3 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.2","description":"How many stage 3 pressure ulcers does the patient have?"},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"Number of Stage 4 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.3","description":"The patient has a certain number of Stage 4 pressure ulcers."},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.4","description":"How many unstageable pressure ulcers/injuries does the patient have due to a non-removable dressing/device?"},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.5","description":"How many unstageable pressure ulcers does the patient have due to coverage of the wound bed by slough and/or eschar?"},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.6","description":"The patient has a certain number of unstageable pressure injuries that present as deep tissue injury."},{"linkId":"Section-13/M0300","prefix":"M0300","text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0"},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1"},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2"},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3"},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4"},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5"},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6"}],"id":"item.11.item.7","description":"The form is asking for the current number of unhealed pressure ulcers/injuries at each stage that the patient has."},{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0","description":"The patient's condition is at Stage 1, where there is intact skin with non-blanchable redness of a localized area, usually over a bony prominence. It is noted that darkly pigmented skin may not exhibit visible blanching. In such cases, dark skin tones may only appear with persistent blue or purple hues."},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1","description":"The patient is at stage 2, which indicates a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. This may also present as an intact or open/ruptured blister."},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2","description":"The patient is at stage 3, which indicates full thickness tissue loss. At this stage, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but it does not obscure the depth of tissue loss. This stage may also include undermining and tunneling."},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3","description":"The patient has stage 4 skin integrity, characterized by full thickness tissue loss with exposed bone, tendon, or muscle. There may be slough or eschar present on some parts of the wound bed, and the condition often includes undermining and tunneling."},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4","description":"The patient has an unstageable condition due to a non-removable dressing or device, although the exact stage is known but cannot be identified because of the non-removable dressing or device."},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5","description":"The patient has a known, but unstageable wound due to the coverage of the wound bed by slough and/or eschar."},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6","description":"The patient has an unstageable deep tissue injury."},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"Number of Stage 1 pressure injuries","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.8","description":"How many Stage 1 pressure injuries does the patient have?"},{"linkId":"Section-14","code":[{"system":"http://loinc.org","code":"88872-7","display":"IRF-PAI v2.0 - Medications - admission [CMS Assessment]"}],"text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/N2001","prefix":"N2001","text":"Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}],"id":"item.12.item.0"},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Medication Follow-up. Did the {facility/setting} contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.12.item.1"}],"id":"item.12","description":"In Section N of the form, the medications that the patient is currently taking are listed."},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}],"id":"item.12.item.0","description":"Did a complete drug regimen review identify any potential clinically significant medication issues for the patient? The options are 'Yes', 'No', and 'Not applicable'."},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Medication Follow-up. Did the {facility/setting} contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.12.item.1","description":"Did the facility or setting in question contact a physician or a physician's designee by midnight of the following calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues related to the patient?"},{"linkId":"Section-15","code":[{"system":"http://loinc.org","code":"83261-8","display":"IRF-PAI v3.0 - Special treatments, procedures, and programs - admission [CMS Assessment]"}],"text":"Section O: Special Treatments, Procedures, and Programs","type":"group","readOnly":true,"item":[{"linkId":"Section-15/O0100","prefix":"O0100","text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that were performed","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}],"id":"item.13.item.0"}],"id":"item.13","description":"In Section O of the form, the patient is asked about special treatments, procedures, and programs they may have undergone."},{"linkId":"Section-15/O0100","prefix":"O0100","text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that were performed","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}],"id":"item.13.item.0","description":"Please indicate all of the special treatments, procedures, and programs that were performed on the patient."},{"linkId":"Section-19","text":"Section Z: Assessment Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-19/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0"},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1"},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2"},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3"},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4"},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5"},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6"},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7"},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8"},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9"},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10"},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11"}],"id":"item.14.item.0"}],"id":"item.14","description":"In Section Z of the form, the assessment administration for the patient is carried out."},{"linkId":"Section-19/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0"},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1"},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2"},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3"},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4"},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5"},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6"},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7"},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8"},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9"},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10"},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11"}],"id":"item.14.item.0","description":"The signature of the person who completed the assessment for the patient is required."},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0","description":"The patient filled out the Signature, Title, Sections, and Date Section Completed A on the form."},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1","description":"The patient needs to provide their signature, title, and date for the sections they have completed in Section B."},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2","description":"The patient needs to complete the signature, title, and sections of the form, and indicate the date the section C was completed."},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3","description":"The patient is required to provide their signature, title, and date the sections that have been completed in Section D."},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4","description":"The patient needs to provide their signature, title, and the sections they have completed, along with the date they finished section E."},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5","description":"The patient's form contains a section for the signature, title, and sections, and also records the date the section was completed."},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6","description":"The patient is required to provide their signature, title, fill in the sections, and add the date the section was completed on form G."},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7","description":"The patient's form contains sections for signature, title, and date, which need to be completed. In section H, the form is completed."},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8","description":"The section titled \"Signature, Title, Sections, Date Section Completed I\" requires the patient's signature, their title, and the date on which they completed the section."},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9","description":"The patient completed the signature, title, and sections on the form, and dated it on section J."},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10","description":"The patient is required to provide their signature and title in the specified sections, and the date when they completed the form."},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11","description":"The patient must provide their signature and title, complete all sections, and include the date that they completed the form."},{"linkId":"Section-49","text":"Therapy Information","type":"group","readOnly":true,"item":[{"linkId":"Section-49/O0401","prefix":"O0401","text":"Week 1: total number of minutes provided","type":"text","repeats":false,"readOnly":false,"item":[{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0"}],"id":"item.15.item.0"}],"id":"item.15","description":"The patient's therapy information is required."},{"linkId":"Section-49/O0401","prefix":"O0401","text":"Week 1: total number of minutes provided","type":"text","repeats":false,"readOnly":false,"item":[{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0"}],"id":"item.15.item.0","description":"In the first week, what was the total number of minutes of care provided to the patient?"},{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0","description":"Does the patient require physical therapy?"},null],"_id":"Cia87N8iTMwovJ6oT"} {"responseType":"QuestionnaireResponse","questionnaire":"IRF-PAI-IA-3.0","id":"IRF-PAI-IA-3.0-1","title":"Inpatient Rehabilitation Facility Patient Assessment Instrument - IRF Admission","description":"Assessment data collected on all Medicare Part A fee-for-service patients who receive services under Part A from an inpatient rehabilitation facility (IRF) at admission and upon discharge.","status":"draft","authored":"2024-09-20T06:34:32.500Z","item":[{"linkId":"Section-45","text":"Discharge Information","type":"group","readOnly":true,"item":[{"linkId":"Section-45/40","prefix":"40","text":"Discharge date","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.0"}],"id":"item.0","description":"The patient's discharge information is ready to be reviewed."},{"linkId":"Section-45/40","prefix":"40","text":"Discharge date","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.0","description":"What is the patient's discharge date?"},{"linkId":"Section-38","code":[{"system":"http://loinc.org","code":"85395-2","display":"IRF-PAI v3.0 - Identification information [CMS Assessment]"}],"text":"Identification Information","type":"group","readOnly":true,"item":[{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.0"},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.1"},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.1.item.2"},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.1.item.3"},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.4"},{"linkId":"Section-38/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.1.item.5"},{"linkId":"Section-38/A0800","prefix":"A0800","text":"Gender","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}],"id":"item.1.item.6"},{"linkId":"Section-38/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.7"},{"linkId":"Section-38/A1200","prefix":"A1200","text":"Marital Status","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}],"id":"item.1.item.8"},{"linkId":"Section-38/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.9"},{"linkId":"Section-38/11","prefix":"11","text":"Zip Code of {Patient's/Resident's} Pre-Hospital Residence","type":"text","repeats":false,"readOnly":false,"maxLength":5,"id":"item.1.item.10"},{"linkId":"Section-38/13","prefix":"13","text":"Assessment Reference Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.11"},{"linkId":"Section-38/14","prefix":"14","text":"Admission Class","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27331-0","display":"Initial rehab"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27332-8","display":"Evaluation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4395-5","display":"Readmission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27335-1","display":"Continuing rehabilitation"}}],"id":"item.1.item.12"},{"linkId":"Section-38/17","prefix":"17","text":"Pre-hospital Living With (Code only if item {Pre-hospital Living Setting} is Home)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27350-0","display":"Alone"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27351-8","display":"Family/Relatives"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27352-6","display":"Friends"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27353-4","display":"Attendant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}],"id":"item.1.item.13"},{"linkId":"Section-38/15A","prefix":"15A","text":"Admit From","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.14"},{"linkId":"Section-38/16A","prefix":"16A","text":"Pre-hospital Living Setting. Use codes from {Admit From}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.15"},{"linkId":"Section-38/1","prefix":"1","text":"{Facility/Provider} Information","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0"}],"id":"item.1.item.16"},{"linkId":"Section-38/5B","prefix":"5B","text":"{Patient/Resident} Identification Number","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.17"},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}],"id":"item.1.item.18"}],"id":"item.1","description":"The form requires the patient's identification information."},{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.0","description":"What is the patient's CMS Certification Number (CCN)?"},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.1","description":"What is the patient's first name?"},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.1.item.2","description":"What is the patient's last name?"},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.1.item.3","description":"What is the patient's Social Security Number?"},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.4","description":"What is the patient's Medicare number?"},{"linkId":"Section-38/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.1.item.5","description":"The patient should enter a \"+\" in the section labeled \"Medicaid Number\" if their Medicaid application is pending, or a \"N\" if they are not a Medicaid recipient."},{"linkId":"Section-38/A0800","prefix":"A0800","text":"Gender","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}],"id":"item.1.item.6","description":"What is the patient's gender? The options are male, female, or other."},{"linkId":"Section-38/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.7","description":"What is the patient's birth date?"},{"linkId":"Section-38/A1200","prefix":"A1200","text":"Marital Status","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}],"id":"item.1.item.8","description":"What is the patient's marital status? Is they married, single, divorced, or widowed?"},{"linkId":"Section-38/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.9","description":"The admission date of the patient is when they were admitted to the hospital."},{"linkId":"Section-38/11","prefix":"11","text":"Zip Code of {Patient's/Resident's} Pre-Hospital Residence","type":"text","repeats":false,"readOnly":false,"maxLength":5,"id":"item.1.item.10","description":"What is the zip code of the patient's pre-hospital residence?"},{"linkId":"Section-38/13","prefix":"13","text":"Assessment Reference Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.11","description":"The assessment reference date for the patient has been set."},{"linkId":"Section-38/14","prefix":"14","text":"Admission Class","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27331-0","display":"Initial rehab"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27332-8","display":"Evaluation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4395-5","display":"Readmission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27335-1","display":"Continuing rehabilitation"}}],"id":"item.1.item.12","description":"The admission class for the patient is being determined."},{"linkId":"Section-38/17","prefix":"17","text":"Pre-hospital Living With (Code only if item {Pre-hospital Living Setting} is Home)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Alone"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27350-0","display":"Alone"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Family / Relatives"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27351-8","display":"Family/Relatives"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Friends"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27352-6","display":"Friends"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Attendant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27353-4","display":"Attendant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Other"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}],"id":"item.1.item.13","description":"The patient's pre-hospital living situation should be coded only if the patient was living at home before hospitalization."},{"linkId":"Section-38/15A","prefix":"15A","text":"Admit From","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.14","description":"From where was the patient admitted?"},{"linkId":"Section-38/16A","prefix":"16A","text":"Pre-hospital Living Setting. Use codes from {Admit From}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.15","description":"The pre-hospital living setting of the patient is determined by using codes from the 'Admit From' category."},{"linkId":"Section-38/1","prefix":"1","text":"{Facility/Provider} Information","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0"}],"id":"item.1.item.16","description":"The form contains a section for the patient to provide information about the facility or provider they are connected with.\n"},{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0","description":"What is the name of the facility or provider for the patient?"},{"linkId":"Section-38/5B","prefix":"5B","text":"{Patient/Resident} Identification Number","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.17","description":"What is the patient's or resident's identification number?"},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}],"id":"item.1.item.18","description":"The patient should check all the boxes that apply to their race or ethnicity."},{"linkId":"Section-41","code":[{"system":"http://loinc.org","code":"87415-6","display":"IRF-PAI v3.0 - Medical Info [CMS Assessment]"}],"text":"Medical Information","type":"group","readOnly":true,"item":[{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Height (in inches). Record most recent height measure since {admission}","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"Weight (in pounds). Base weight on most recent measure in last {specify time period in days}; measure weight consistently, according to standard {facility/setting} practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer","repeats":false,"readOnly":false,"maxLength":3,"id":"item.2.item.1"},{"linkId":"Section-41/21A","prefix":"21A","text":"Impairment Group - Admission: Condition requiring admission to rehabilitation; code according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.2.item.2"},{"linkId":"Section-41/23","prefix":"23","text":"Date of Onset of Impairment","type":"open-choice","repeats":false,"readOnly":false,"id":"item.2.item.3"},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Are there any arthritis conditions recorded in items {impairment group, etiologic diagnosis, or comorbid conditions} that meet all the regulatory requirements for {IRF} classification","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.2.item.4"},{"linkId":"Section-41/22","prefix":"22","text":"Etiologic Diagnosis: (Use ICD codes to indicate the etiologic problem that led to the condition for which the {patient/resident} is receiving rehabilitation)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0"},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1"},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2"}],"id":"item.2.item.5"},{"linkId":"Section-41/24","prefix":"24","text":"Comorbid Conditions. Use ICD codes to enter comorbid medical conditions","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8"},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18"},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21"},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24"}],"id":"item.2.item.6"},{"linkId":"Section-41/21","prefix":"21","text":"Impairment group","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0"}],"id":"item.2.item.7"}],"id":"item.2","description":"The form is requesting the patient's medical information."},{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Height (in inches). Record most recent height measure since {admission}","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"The form asks for the patient's height in inches and requests the most recent measurement since their admission."},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"Weight (in pounds). Base weight on most recent measure in last {specify time period in days}; measure weight consistently, according to standard {facility/setting} practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer","repeats":false,"readOnly":false,"maxLength":3,"id":"item.2.item.1","description":"The patient's weight, in pounds, should be based on the most recent measurement taken within the specified time period in days. It's important to measure the patient's weight consistently, adhering to the standard practice of the facility or setting. For instance, this could be done in the morning after voiding, before a meal, with shoes off, and so on."},{"linkId":"Section-41/21A","prefix":"21A","text":"Impairment Group - Admission: Condition requiring admission to rehabilitation; code according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.2.item.2","description":"The impairment group on the admission form refers to the condition that required the patient's admission to rehabilitation, which should be coded according to Appendix A."},{"linkId":"Section-41/23","prefix":"23","text":"Date of Onset of Impairment","type":"open-choice","repeats":false,"readOnly":false,"id":"item.2.item.3","description":"When did the patient's impairment begin?"},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Are there any arthritis conditions recorded in items {impairment group, etiologic diagnosis, or comorbid conditions} that meet all the regulatory requirements for {IRF} classification","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.2.item.4","description":"Does the patient have any arthritis conditions recorded in the impairment group, etiologic diagnosis, or comorbid conditions that meet all the regulatory requirements for Inpatient Rehabilitation Facility (IRF) classification?"},{"linkId":"Section-41/22","prefix":"22","text":"Etiologic Diagnosis: (Use ICD codes to indicate the etiologic problem that led to the condition for which the {patient/resident} is receiving rehabilitation)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0"},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1"},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2"}],"id":"item.2.item.5","description":"The etiologic diagnosis requires the use of ICD codes to indicate the underlying problem that led to the condition for which the patient is receiving rehabilitation."},{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0","description":"The form for the patient includes a section labeled \"Etiologic Diagnosis A\"."},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1","description":"The form for the patient includes a section labeled \"Etiologic Diagnosis B\"."},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2","description":"The form asks for the patient's etiologic diagnosis C."},{"linkId":"Section-41/24","prefix":"24","text":"Comorbid Conditions. Use ICD codes to enter comorbid medical conditions","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8"},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18"},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21"},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24"}],"id":"item.2.item.6","description":"The patient is instructed to use ICD codes to enter their comorbid medical conditions under the section labeled \"Comorbid Conditions.\""},{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0","description":"Does the patient have a comorbid condition A?"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1","description":"Does the patient have Comorbid Condition B?"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2","description":"Does the patient have Comorbid Condition C?"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3","description":"Does the patient have any comorbid condition D?"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4","description":"Does the patient have a comorbid condition E?"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5","description":"Does the patient have a comorbid condition F?"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6","description":"Does the patient have comorbid condition G?"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7","description":"Does the patient have a comorbid condition H?"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8","description":"Does the patient have a comorbid condition? If yes, please specify."},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9","description":"Does the patient have Comorbid Condition J?"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10","description":"Does the patient have a comorbid condition K?"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11","description":"Does the patient have any comorbid condition L?"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12","description":"Does the patient have a comorbid condition M?"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13","description":"Does the patient have a comorbid condition N?"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14","description":"Does the patient have any comorbid conditions?"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15","description":"Does the patient have a comorbid condition P?"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16","description":"Does the patient have a comorbid condition?"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17","description":"Does the patient have a comorbid condition R?"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18","description":"The form asks if the patient has any comorbid conditions."},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19","description":"Does the patient have a comorbid condition T?"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20","description":"Does the patient have a comorbid condition U?"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21","description":"Does the patient have a comorbid condition V? Please indicate yes or no."},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22","description":"Does the patient have any comorbid condition W?"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23","description":"Does the patient have a comorbid condition X?"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24","description":"Does the patient have comorbid condition Y?"},{"linkId":"Section-41/21","prefix":"21","text":"Impairment group","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0"}],"id":"item.2.item.7","description":"What is the patient's impairment group?"},{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0","description":"What is the impairment group upon admission for the patient?"},{"linkId":"Section-40","code":[{"system":"http://loinc.org","code":"85401-8","display":"IRF-PAI - Payer information [CMS Assessment]"}],"text":"Payer Information","type":"group","readOnly":true,"item":[{"linkId":"Section-40/20","prefix":"20","text":"Payment Source","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0"},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1"}],"id":"item.3.item.0"}],"id":"item.3","description":"The form requires the patient's payer information."},{"linkId":"Section-40/20","prefix":"20","text":"Payment Source","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0"},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1"}],"id":"item.3.item.0","description":"The payment source for the patient is being determined."},{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0","description":"The primary source of information regarding the patient's health condition is the patient themselves."},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1","description":"The form for the patient includes a section titled \"Secondary Source.\""},{"linkId":"Section-2","code":[{"system":"http://loinc.org","code":"88522-8","display":"IRF-PAI v2.0 - Hearing, speech, and vision - admission [CMS Assessment]"}],"text":"Section B: Hearing, Speech, and Vision","type":"group","readOnly":true,"item":[{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}],"id":"item.4.item.0"},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}],"id":"item.4.item.1"}],"id":"item.4","description":"In Section B of the form, the patient's hearing, speech, and vision capabilities are assessed."},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}],"id":"item.4.item.0","description":"The patient's expression of ideas and wants, considering both verbal and non-verbal expression and excluding language barriers, should be evaluated. Does the patient often communicate their ideas and desires clearly? The answer could be 'Always', 'Often', 'Sometimes', 'Rarely', or 'Never'."},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}],"id":"item.4.item.1","description":"Does the patient understand both verbal and non-verbal content with the use of a hearing aid or device, if used, while excluding any language barriers?"},{"linkId":"Section-3","code":[{"system":"http://loinc.org","code":"88524-4","display":"IRF-PAI v2.0 - Cognitive patterns - admission [CMS Assessment]"}],"text":"Section C: Cognitive Patterns","type":"group","readOnly":true,"item":[{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all {patients/residents}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.5.item.0"},{"linkId":"Section-3/C0200","prefix":"C0200","text":"Repetition of Three Words - Ask {patient/resident}: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}],"id":"item.5.item.1"},{"linkId":"Section-3/C0500","prefix":"C0500","text":"BIMS Summary Score. Add scores for {Brief Interview for Mental Status questions} and fill in total score (00-15). Enter 99 if the {patient/resident} was unable to complete the interview","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.2"},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the Staff Assessment for Mental Status be Conducted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes ({patient/resident} was unable to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}],"id":"item.5.item.3"},{"linkId":"Section-3/C0300","prefix":"C0300","text":"BIMS: Temporal Orientation (orientation to year, month, and day)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0"},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1"},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2"}],"id":"item.5.item.4"},{"linkId":"Section-3/C0400","prefix":"C0400","text":"Recall. Ask {patient/resident}: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0"},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1"},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2"}],"id":"item.5.item.5"},{"linkId":"Section-3/C0900","prefix":"C0900","text":"Memory/Recall Ability: Check all that the {patient/resident} was normally able to recall","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above were recalled"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}],"id":"item.5.item.6"}],"id":"item.5","description":"In Section C of the form, the patient's cognitive patterns are assessed."},{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all {patients/residents}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.5.item.0","description":"Should a Brief Interview for Mental Status be conducted? It is suggested to attempt to conduct the interview with all patients or residents."},{"linkId":"Section-3/C0200","prefix":"C0200","text":"Repetition of Three Words - Ask {patient/resident}: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}],"id":"item.5.item.1","description":"The form asks the patient, \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" The number of words repeated after the first attempt is then recorded by the medical professional."},{"linkId":"Section-3/C0500","prefix":"C0500","text":"BIMS Summary Score. Add scores for {Brief Interview for Mental Status questions} and fill in total score (00-15). Enter 99 if the {patient/resident} was unable to complete the interview","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.2","description":"The BIMS Summary Score should be calculated by adding the scores for the Brief Interview for Mental Status questions and filling in the total score, which ranges from 00 to 15. If the patient or resident was unable to complete the interview, the score to be entered should be 99."},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the Staff Assessment for Mental Status be Conducted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes ({patient/resident} was unable to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}],"id":"item.5.item.3","description":"Should the staff assessment for the patient's mental status be conducted?"},{"linkId":"Section-3/C0300","prefix":"C0300","text":"BIMS: Temporal Orientation (orientation to year, month, and day)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0"},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1"},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2"}],"id":"item.5.item.4","description":"The patient's BIMS assessment includes a temporal orientation evaluation, which evaluates their orientation to the current year, month, and day."},{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0","description":"The form asks the patient or resident, \"Please tell me what year it is right now.\" They are able to report the correct year."},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1","description":"The form asks the patient or resident, \"What month are we in right now?\" The patient or resident should be able to report the correct month."},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2","description":"Ask the patient or resident: \"What day of the week is today?\" They should be able to report the correct day of the week."},{"linkId":"Section-3/C0400","prefix":"C0400","text":"Recall. Ask {patient/resident}: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0"},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1"},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2"}],"id":"item.5.item.5","description":"The doctor asks the patient, \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If the patient is unable to remember a word, the doctor gives a cue, such as 'something to wear', 'a color', or 'a piece of furniture', for that particular word."},{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0","description":"The patient is able to recall the word \"sock\"."},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1","description":"The patient is able to recall the color \"blue\"."},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2","description":"Is the patient able to recall \"bed\"?"},{"linkId":"Section-3/C0900","prefix":"C0900","text":"Memory/Recall Ability: Check all that the {patient/resident} was normally able to recall","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above were recalled"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}],"id":"item.5.item.6","description":"The patient's or resident's ability to recall normally should be assessed. Please check all that apply."},{"linkId":"Section-37","code":[{"system":"http://loinc.org","code":"88482-5","display":"Functional abilities and goals - admission [CMS Assessment]"}],"text":"Section GG: Functional Abilities and Goals","type":"group","readOnly":true,"item":[{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.0"},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. 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Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.1"},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.2"},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.3"},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.4"},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.27"},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. 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Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.28"},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the {patient/resident} use a wheelchair and/or scooter? - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.6.item.29"},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.30"},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.31"},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. 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Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.33"},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.34"},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.35"},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.40"},{"linkId":"Section-37/GG0170P1","prefix":"GG0170P1","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.41"},{"linkId":"Section-37/GG0130E2","prefix":"GG0130E2","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. 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Does not include the ability to open/close door or fasten seat belt. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.49"},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.50"},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.51"},{"linkId":"Section-37/GG0100","prefix":"GG0100","text":"Prior Functioning: Everyday Activities. Indicate the {patient's/resident's} usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0"},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1"},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2"},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3"}],"id":"item.6.item.52"},{"linkId":"Section-37/GG0130","prefix":"GG0130","text":"Self-Care.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0"},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1"}],"id":"item.6.item.53"},{"linkId":"Section-37/GG0170","prefix":"GG0170","text":"Mobility.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0"},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1"}],"id":"item.6.item.54"},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Prior Device Use. Indicate devices and aids used by the {patient/resident} prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.6.item.55"}],"id":"item.6","description":"In Section GG of the form, the patient's functional abilities and goals are documented."},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.0","description":"The question for the patient or resident is about their eating ability. Specifically, can they use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them? This is in reference to their performance upon admission."},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.1","description":"The form asks about the patient's oral hygiene, specifically their ability to use suitable items to clean their teeth. It also inquires if they have dentures and if so, their ability to insert and remove them from the mouth, as well as manage denture soaking and rinsing with the use of equipment. This is relevant to their admission performance."},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.2","description":"The form asks about the patient's ability to maintain perineal hygiene and adjust their clothes before and after voiding or having a bowel movement. If the patient is managing an ostomy, it includes the task of wiping the opening but not managing the equipment. This is pertaining to their performance upon admission."},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.3","description":"The discharge goal for the patient is to have the ability to use suitable utensils in order to bring food and/or liquid to their mouth and to be able to swallow food and/or liquid once the meal is placed before them."},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.4","description":"The form inquires about the patient's oral hygiene: their ability to use suitable items to clean their teeth. It also asks if the patient has dentures and if so, it assesses their ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with the use of equipment. The goal is to prepare the patient for discharge."},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.5","description":"The discharge goal for the patient is related to toileting hygiene, which refers to their ability to maintain perineal hygiene, adjust clothing before and after voiding or having a bowel movement. If they are managing an ostomy, this also includes wiping the opening, but not managing the equipment."},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.6","description":"The form asks about the patient's ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed, as part of their admission performance."},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.7","description":"The form asks about the patient's admission performance regarding their ability to move from sitting on the side of the bed to lying flat on the bed."},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.8","description":"The form is asking about the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. This is in reference to their admission performance."},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.9","description":"The discharge goal for the patient is to acquire the ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed."},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.10","description":"The discharge goal for the patient is to have the ability to move from sitting on the side of the bed to lying flat on the bed."},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.11","description":"The discharge goal for the patient is to have the ability to move from lying on their back to sitting on the side of the bed without any back support."},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.12","description":"The form asks the patient about their ability to come to a standing position from sitting in a chair, a wheelchair, or on the side of the bed, and requests them to rate their admission performance."},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.13","description":"The form is asking about the patient's ability to transfer to and from a bed to a chair or wheelchair. It is inquiring about their admission performance."},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.14","description":"The form asks about the patient's ability to transfer to and from a toilet or commode on their own as it pertains to their performance upon admission."},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.15","description":"The question on the form asks about the patient's admission performance in relation to their ability to walk. Specifically, it inquires whether, once standing, the patient can walk at least 10 feet in a room, corridor, or similar space."},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.16","description":"Once standing, the patient has the ability to walk at least 50 feet and make two turns as part of their admission performance."},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.17","description":"The form inquires about the patient's capability to walk at least 150 feet in a corridor or similar space once they are standing. This is referred to as the \"Admission Performance\" aspect."},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.18","description":"Once the patient is seated in the wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. This is a requirement for admission performance."},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.19","description":"The admission performance form includes a question regarding the patient's ability, once seated in a wheelchair or scooter, to wheel at least 150 feet in a corridor or similar space."},{"linkId":"Section-37/GG0170K3","prefix":"GG0170K3","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Discharge Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.20","description":"The form asks about the patient's ability to walk at least 150 feet in a corridor or similar space once they are standing, with the label of \"Discharge Performance\"."},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.21","description":"The discharge goal for the patient is to develop the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed."},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.22","description":"The form asks about the patient's ability to transfer themselves to and from a bed to a chair or wheelchair. The discharge goal is to evaluate this capability."},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.23","description":"The discharge goal for the patient refers to their ability to independently get on and off a toilet or commode."},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.24","description":"The question on the form is asking about the patient's ability, once standing, to walk at least 10 feet in a room, corridor, or similar space. The goal is that the patient should be able to do this upon discharge."},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.25","description":"The label is asking about the patient's ability, once standing, to walk a minimum of 50 feet and make two turns. The goal is to achieve this by the time of discharge."},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.26","description":"The form asks if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The response options for this question are 'discharge goal'."},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.27","description":"The discharge goal for the patient is to be able to wheel at least 50 feet and make two turns once seated in a wheelchair or scooter."},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.28","description":"The discharge goal for the patient is to gain the ability to wheel at least 150 feet in a corridor or similar space once seated in a wheelchair or scooter."},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the {patient/resident} use a wheelchair and/or scooter? - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.6.item.29","description":"Does the patient or resident use a wheelchair and/or scooter upon admission?"},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.30","description":"The form is asking the patient to indicate the type of wheelchair or scooter they use upon admission."},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.31","description":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission."},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.32","description":"The form asks about the patient's ability to shower or bathe themselves, which includes tasks such as washing, rinsing, and drying themselves, but does not include washing their back and hair, nor transferring in and out of the tub or shower. The question relates to their performance upon admission."},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.33","description":"The admission form inquires about the patient's ability to dress and undress above the waist, including handling fasteners if applicable, in the section labeled \"Upper body dressing.\""},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.34","description":"On the admission performance form, there is a question about the patient's ability to dress and undress below the waist, including handling fasteners. This does not include dealing with footwear."},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.35","description":"Does the patient have the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable? Please evaluate their performance upon admission."},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.36","description":"On the admission form, it asks about the patient's ability to transfer in and out of a car or van on the passenger side, without including the ability to open or close the door or fasten the seat belt."},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.37","description":"The form asks if the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, either indoors or outdoors. This is in reference to their admission performance."},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.38","description":"The form asks about the patient's ability to go up and down a curb and/or up and down one step in regards to their admission performance."},{"linkId":"Section-37/GG0170N1","prefix":"GG0170N1","text":"4 steps: The ability to go up and down four steps with or without a rail. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.39","description":"The form asks about the patient's ability to go up and down four steps with or without a rail in terms of admission performance."},{"linkId":"Section-37/GG0170O1","prefix":"GG0170O1","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.40","description":"The form asks whether the patient has the ability to go up and down 12 steps with or without a rail as part of their admission performance."},{"linkId":"Section-37/GG0170P1","prefix":"GG0170P1","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.41","description":"The form asks about the patient's admission performance in terms of their ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor."},{"linkId":"Section-37/GG0130E2","prefix":"GG0130E2","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.42","description":"The discharge goal for the patient is to be able to shower or bathe themselves. This means the patient should have the ability to wash, rinse, and dry themselves, excluding washing of the back and hair. It does not include transferring in or out of the tub or shower."},{"linkId":"Section-37/GG0130F2","prefix":"GG0130F2","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.43","description":"The discharge goal for the patient is to be able to dress and undress above the waist, which includes handling any fasteners, if applicable, on their own."},{"linkId":"Section-37/GG0130G2","prefix":"GG0130G2","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.44","description":"The discharge goal for the patient is to be able to independently dress and undress their lower body, below the waist, including handling fasteners, but not including footwear."},{"linkId":"Section-37/GG0130H2","prefix":"GG0130H2","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.45","description":"The form asks about the patient's ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable, and what the discharge goal for this ability is."},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.46","description":"The discharge goal for the patient is to have the ability to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten their seat belt."},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.47","description":"The form asks if the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoor or outdoor, with the discharge goal being the endpoint."},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.48","description":"The question on the form asks about the patient's ability to go up and down a curb and/or up and down one step. The label for this section is \"Discharge Goal\"."},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"4 steps: The ability to go up and down four steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.49","description":"The discharge goal for the patient is to have the ability to go up and down four steps with or without a rail."},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.50","description":"The discharge goal for the patient is to develop the ability to go up and down 12 steps with or without the use of a rail."},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.51","description":"The discharge goal for the patient is to have the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor."},{"linkId":"Section-37/GG0100","prefix":"GG0100","text":"Prior Functioning: Everyday Activities. Indicate the {patient's/resident's} usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0"},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1"},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2"},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3"}],"id":"item.6.item.52","description":"Please indicate the patient's usual ability with everyday activities prior to their current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0","description":"Please code the patient's or resident's need for assistance with bathing, dressing, using the toilet, and eating prior to their current illness, exacerbation, or injury for the Self-Care section."},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1","description":"The form requests the code for the patient's or resident's need for assistance with walking from room to room, with or without a device such as a cane, crutch, or walker, prior to the current illness, exacerbation, or injury to determine their level of indoor mobility and ambulation."},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2","description":"The form asks to code the patient's or resident's need for assistance with internal or external stairs, with or without a device such as a cane, crutch, or walker, prior to the current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3","description":"The form asks to code the patient's or resident's need for assistance with planning regular tasks, such as shopping or remembering to take medication, prior to their current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0130","prefix":"GG0130","text":"Self-Care.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0"},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1"}],"id":"item.6.item.53","description":"The patient is capable of self-care."},{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0","description":"For the category of Self-Care, please code the patient's usual performance at the time of admission for each activity using the 6-point scale. If the activity was not attempted at the time of admission, please code the reason."},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1","description":"Please code the patient's or resident's self-care discharge goals using the 6-point scale. The use of codes 07, 09, 10, or 88 is permissible to code the discharge goals."},{"linkId":"Section-37/GG0170","prefix":"GG0170","text":"Mobility.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0"},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1"}],"id":"item.6.item.54","description":"The patient's mobility status is being assessed."},{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0","description":"For the section on mobility, please code the patient's or resident's usual performance at the time of admission for each activity using the 6-point scale. If a certain activity was not attempted at the time of admission, code the reason."},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1","description":"The form instructs the user to code the patient's or resident's discharge goals using the 6-point scale. The use of codes 07, 09, 10, or 88 is permissible to code the discharge goals."},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Prior Device Use. Indicate devices and aids used by the {patient/resident} prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.6.item.55","description":"Please indicate the devices and aids that the patient or resident used prior to their current illness, exacerbation, or injury. Check all that apply."},{"linkId":"Section-8","code":[{"system":"http://loinc.org","code":"83237-8","display":"Bladder and bowel [CMS Assessment]"}],"text":"Section H: Bladder and Bowel","type":"group","readOnly":true,"item":[{"linkId":"Section-8/H0400","prefix":"H0400","text":"Bowel Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}],"id":"item.7.item.0"},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Bladder Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}],"id":"item.7.item.1"}],"id":"item.7","description":"In section H of the form, the patient's bladder and bowel conditions are addressed."},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Bowel Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}],"id":"item.7.item.0","description":"Please select the one category that best describes the bowel continence of the patient or resident."},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Bladder Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}],"id":"item.7.item.1","description":"Please select the one category that best describes the patient's or resident's bladder continence."},{"linkId":"Section-9","code":[{"system":"http://loinc.org","code":"83264-2","display":"IRF-PAI - Active diagnoses [CMS Assessment]"}],"text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0000","prefix":"I0000","text":"Active Diagnoses in the last 7 days: Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.8.item.0"}],"id":"item.8","description":"In Section I of the form, the patient's active diagnoses are listed."},{"linkId":"Section-9/I0000","prefix":"I0000","text":"Active Diagnoses in the last 7 days: Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.8.item.0","description":"The patient has been asked to indicate all of their active diagnoses from the last 7 days on the form. They should check all that apply. The diagnoses provided in parentheses are just examples and should not be considered as an all-inclusive list."},{"linkId":"Section-10","code":[{"system":"http://loinc.org","code":"83273-3","display":"IRF-PAI - Health conditions - admission [CMS Assessment]"}],"text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J1750","prefix":"J1750","text":"History of Falls: Has the {patient/resident} had two or more falls in the past year or any fall with injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.0"},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Prior Surgery. Did the {patient/resident} have major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.1"}],"id":"item.9","description":"In Section J of the form, the patient's health conditions are being evaluated."},{"linkId":"Section-10/J1750","prefix":"J1750","text":"History of Falls: Has the {patient/resident} had two or more falls in the past year or any fall with injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.0","description":"Does the patient or resident have a history of having two or more falls in the past year, or any fall that resulted in injury in the past year?"},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Prior Surgery. Did the {patient/resident} have major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.1","description":"Did the patient or resident have any major surgery during the 100 days prior to their admission?"},{"linkId":"Section-11","code":[{"system":"http://loinc.org","code":"83244-4","display":"IRF-PAI v2.0 - Swallowing/nutritional status - admission [CMS Assessment]"}],"text":"Section K: Swallowing/Nutritional Status","type":"group","readOnly":true,"item":[{"linkId":"Section-11/K0110","prefix":"K0110","text":"Swallowing/Nutritional Status. Indicate the {patient's/resident's} usual ability to swallow: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Regular food - Solids and liquids swallowed safely without supervision or modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Modified food consistency/supervision - {Patient/Resident} requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Tube/parenteral feeding - Tube/parenteral feeding used wholly or partially as a means of sustenance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}],"id":"item.10.item.0"}],"id":"item.10","description":"In Section K of the form, the patient's swallowing and nutritional status is assessed."},{"linkId":"Section-11/K0110","prefix":"K0110","text":"Swallowing/Nutritional Status. Indicate the {patient's/resident's} usual ability to swallow: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Regular food - Solids and liquids swallowed safely without supervision or modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Modified food consistency/supervision - {Patient/Resident} requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Tube/parenteral feeding - Tube/parenteral feeding used wholly or partially as a means of sustenance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}],"id":"item.10.item.0","description":"Please indicate the patient's usual ability to swallow regarding their swallowing or nutritional status. Check all that apply."},{"linkId":"Section-13","code":[{"system":"http://loinc.org","code":"85055-2","display":"IRF-PAI v3.0, LCDS v4.00 - Skin conditions - admission [CMS Assessment]"}],"text":"Section M: Skin Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-13/M0210","prefix":"M0210","text":"Unhealed Pressure Ulcers/Injuries. Does this {patient/resident} have one or more unhealed pressure ulcers/injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.11.item.0"},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"Number of Stage 2 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.1"},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"Number of Stage 3 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.2"},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"Number of Stage 4 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.3"},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.4"},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.5"},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.6"},{"linkId":"Section-13/M0300","prefix":"M0300","text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0"},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1"},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2"},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3"},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4"},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5"},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6"}],"id":"item.11.item.7"},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"Number of Stage 1 pressure injuries","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.8"}],"id":"item.11","description":"In Section M of the form, the patient's skin conditions are addressed."},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Unhealed Pressure Ulcers/Injuries. Does this {patient/resident} have one or more unhealed pressure ulcers/injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.11.item.0","description":"Does this patient or resident have one or more unhealed pressure ulcers or injuries?"},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"Number of Stage 2 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.1","description":"The patient has how many Stage 2 pressure ulcers?"},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"Number of Stage 3 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.2","description":"How many stage 3 pressure ulcers does the patient have?"},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"Number of Stage 4 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.3","description":"The patient has a certain number of Stage 4 pressure ulcers."},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.4","description":"How many unstageable pressure ulcers/injuries does the patient have due to a non-removable dressing/device?"},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.5","description":"How many unstageable pressure ulcers does the patient have due to coverage of the wound bed by slough and/or eschar?"},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.6","description":"The patient has a certain number of unstageable pressure injuries that present as deep tissue injury."},{"linkId":"Section-13/M0300","prefix":"M0300","text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0"},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1"},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2"},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3"},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4"},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5"},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6"}],"id":"item.11.item.7","description":"The form is asking for the current number of unhealed pressure ulcers/injuries at each stage that the patient has."},{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0","description":"The patient's condition is at Stage 1, where there is intact skin with non-blanchable redness of a localized area, usually over a bony prominence. It is noted that darkly pigmented skin may not exhibit visible blanching. In such cases, dark skin tones may only appear with persistent blue or purple hues."},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1","description":"The patient is at stage 2, which indicates a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. This may also present as an intact or open/ruptured blister."},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2","description":"The patient is at stage 3, which indicates full thickness tissue loss. At this stage, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but it does not obscure the depth of tissue loss. This stage may also include undermining and tunneling."},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3","description":"The patient has stage 4 skin integrity, characterized by full thickness tissue loss with exposed bone, tendon, or muscle. There may be slough or eschar present on some parts of the wound bed, and the condition often includes undermining and tunneling."},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4","description":"The patient has an unstageable condition due to a non-removable dressing or device, although the exact stage is known but cannot be identified because of the non-removable dressing or device."},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5","description":"The patient has a known, but unstageable wound due to the coverage of the wound bed by slough and/or eschar."},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6","description":"The patient has an unstageable deep tissue injury."},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"Number of Stage 1 pressure injuries","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.8","description":"How many Stage 1 pressure injuries does the patient have?"},{"linkId":"Section-14","code":[{"system":"http://loinc.org","code":"88872-7","display":"IRF-PAI v2.0 - Medications - admission [CMS Assessment]"}],"text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/N2001","prefix":"N2001","text":"Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}],"id":"item.12.item.0"},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Medication Follow-up. Did the {facility/setting} contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.12.item.1"}],"id":"item.12","description":"In Section N of the form, the medications that the patient is currently taking are listed."},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}],"id":"item.12.item.0","description":"Did a complete drug regimen review identify any potential clinically significant medication issues for the patient? The options are 'Yes', 'No', and 'Not applicable'."},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Medication Follow-up. Did the {facility/setting} contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.12.item.1","description":"Did the facility or setting in question contact a physician or a physician's designee by midnight of the following calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues related to the patient?"},{"linkId":"Section-15","code":[{"system":"http://loinc.org","code":"83261-8","display":"IRF-PAI v3.0 - Special treatments, procedures, and programs - admission [CMS Assessment]"}],"text":"Section O: Special Treatments, Procedures, and Programs","type":"group","readOnly":true,"item":[{"linkId":"Section-15/O0100","prefix":"O0100","text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that were performed","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}],"id":"item.13.item.0"}],"id":"item.13","description":"In Section O of the form, the patient is asked about special treatments, procedures, and programs they may have undergone."},{"linkId":"Section-15/O0100","prefix":"O0100","text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that were performed","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}],"id":"item.13.item.0","description":"Please indicate all of the special treatments, procedures, and programs that were performed on the patient."},{"linkId":"Section-19","text":"Section Z: Assessment Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-19/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0"},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1"},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2"},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3"},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4"},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5"},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6"},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7"},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8"},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9"},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10"},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11"}],"id":"item.14.item.0"}],"id":"item.14","description":"In Section Z of the form, the assessment administration for the patient is carried out."},{"linkId":"Section-19/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0"},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1"},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2"},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3"},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4"},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5"},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6"},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7"},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8"},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9"},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10"},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11"}],"id":"item.14.item.0","description":"The signature of the person who completed the assessment for the patient is required."},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0","description":"The patient filled out the Signature, Title, Sections, and Date Section Completed A on the form."},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1","description":"The patient needs to provide their signature, title, and date for the sections they have completed in Section B."},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2","description":"The patient needs to complete the signature, title, and sections of the form, and indicate the date the section C was completed."},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3","description":"The patient is required to provide their signature, title, and date the sections that have been completed in Section D."},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4","description":"The patient needs to provide their signature, title, and the sections they have completed, along with the date they finished section E."},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5","description":"The patient's form contains a section for the signature, title, and sections, and also records the date the section was completed."},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6","description":"The patient is required to provide their signature, title, fill in the sections, and add the date the section was completed on form G."},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7","description":"The patient's form contains sections for signature, title, and date, which need to be completed. In section H, the form is completed."},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8","description":"The section titled \"Signature, Title, Sections, Date Section Completed I\" requires the patient's signature, their title, and the date on which they completed the section."},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9","description":"The patient completed the signature, title, and sections on the form, and dated it on section J."},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10","description":"The patient is required to provide their signature and title in the specified sections, and the date when they completed the form."},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11","description":"The patient must provide their signature and title, complete all sections, and include the date that they completed the form."},{"linkId":"Section-49","text":"Therapy Information","type":"group","readOnly":true,"item":[{"linkId":"Section-49/O0401","prefix":"O0401","text":"Week 1: total number of minutes provided","type":"text","repeats":false,"readOnly":false,"item":[{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0"}],"id":"item.15.item.0"}],"id":"item.15","description":"The patient's therapy information is required."},{"linkId":"Section-49/O0401","prefix":"O0401","text":"Week 1: total number of minutes provided","type":"text","repeats":false,"readOnly":false,"item":[{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0"}],"id":"item.15.item.0","description":"In the first week, what was the total number of minutes of care provided to the patient?"},{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0","description":"Does the patient require physical therapy?"},null],"_id":"B4hPnc8pRQgAxXAWW"} {"responseType":"QuestionnaireResponse","questionnaire":"IRF-PAI-IA-3.0","id":"IRF-PAI-IA-3.0-1","title":"Inpatient Rehabilitation Facility Patient Assessment Instrument - IRF Admission","description":"Assessment data collected on all Medicare Part A fee-for-service patients who receive services under Part A from an inpatient rehabilitation facility (IRF) at admission and upon discharge.","status":"draft","authored":"2024-09-20T06:34:32.500Z","item":[{"linkId":"Section-45","text":"Discharge Information","type":"group","readOnly":true,"item":[{"linkId":"Section-45/40","prefix":"40","text":"Discharge date","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.0"}],"id":"item.0","description":"The patient's discharge information is ready to be reviewed."},{"linkId":"Section-45/40","prefix":"40","text":"Discharge date","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.0","description":"What is the patient's discharge date?"},{"linkId":"Section-38","code":[{"system":"http://loinc.org","code":"85395-2","display":"IRF-PAI v3.0 - Identification information [CMS Assessment]"}],"text":"Identification Information","type":"group","readOnly":true,"item":[{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.0"},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.1"},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.1.item.2"},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.1.item.3"},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.4"},{"linkId":"Section-38/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.1.item.5"},{"linkId":"Section-38/A0800","prefix":"A0800","text":"Gender","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}],"id":"item.1.item.6"},{"linkId":"Section-38/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.7"},{"linkId":"Section-38/A1200","prefix":"A1200","text":"Marital Status","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}],"id":"item.1.item.8"},{"linkId":"Section-38/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.9"},{"linkId":"Section-38/11","prefix":"11","text":"Zip Code of {Patient's/Resident's} Pre-Hospital Residence","type":"text","repeats":false,"readOnly":false,"maxLength":5,"id":"item.1.item.10"},{"linkId":"Section-38/13","prefix":"13","text":"Assessment Reference Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.11"},{"linkId":"Section-38/14","prefix":"14","text":"Admission Class","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27331-0","display":"Initial rehab"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27332-8","display":"Evaluation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4395-5","display":"Readmission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27335-1","display":"Continuing rehabilitation"}}],"id":"item.1.item.12"},{"linkId":"Section-38/17","prefix":"17","text":"Pre-hospital Living With (Code only if item {Pre-hospital Living Setting} is Home)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27350-0","display":"Alone"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27351-8","display":"Family/Relatives"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27352-6","display":"Friends"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27353-4","display":"Attendant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}],"id":"item.1.item.13"},{"linkId":"Section-38/15A","prefix":"15A","text":"Admit From","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.14"},{"linkId":"Section-38/16A","prefix":"16A","text":"Pre-hospital Living Setting. Use codes from {Admit From}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.15"},{"linkId":"Section-38/1","prefix":"1","text":"{Facility/Provider} Information","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0"}],"id":"item.1.item.16"},{"linkId":"Section-38/5B","prefix":"5B","text":"{Patient/Resident} Identification Number","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.17"},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}],"id":"item.1.item.18"}],"id":"item.1","description":"The form requires the patient's identification information."},{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.0","description":"What is the patient's CMS Certification Number (CCN)?"},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.1","description":"What is the patient's first name?"},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.1.item.2","description":"What is the patient's last name?"},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.1.item.3","description":"What is the patient's Social Security Number?"},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.4","description":"What is the patient's Medicare number?"},{"linkId":"Section-38/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.1.item.5","description":"The patient should enter a \"+\" in the section labeled \"Medicaid Number\" if their Medicaid application is pending, or a \"N\" if they are not a Medicaid recipient."},{"linkId":"Section-38/A0800","prefix":"A0800","text":"Gender","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}],"id":"item.1.item.6","description":"What is the patient's gender? The options are male, female, or other."},{"linkId":"Section-38/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.7","description":"What is the patient's birth date?"},{"linkId":"Section-38/A1200","prefix":"A1200","text":"Marital Status","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}],"id":"item.1.item.8","description":"What is the patient's marital status? Is they married, single, divorced, or widowed?"},{"linkId":"Section-38/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.9","description":"The admission date of the patient is when they were admitted to the hospital."},{"linkId":"Section-38/11","prefix":"11","text":"Zip Code of {Patient's/Resident's} Pre-Hospital Residence","type":"text","repeats":false,"readOnly":false,"maxLength":5,"id":"item.1.item.10","description":"What is the zip code of the patient's pre-hospital residence?"},{"linkId":"Section-38/13","prefix":"13","text":"Assessment Reference Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.11","description":"The assessment reference date for the patient has been set."},{"linkId":"Section-38/14","prefix":"14","text":"Admission Class","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27331-0","display":"Initial rehab"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27332-8","display":"Evaluation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4395-5","display":"Readmission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27335-1","display":"Continuing rehabilitation"}}],"id":"item.1.item.12","description":"The admission class for the patient is being determined."},{"linkId":"Section-38/17","prefix":"17","text":"Pre-hospital Living With (Code only if item {Pre-hospital Living Setting} is Home)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Alone"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27350-0","display":"Alone"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Family / Relatives"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27351-8","display":"Family/Relatives"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Friends"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27352-6","display":"Friends"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Attendant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27353-4","display":"Attendant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Other"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}],"id":"item.1.item.13","description":"The patient's pre-hospital living situation should be coded only if the patient was living at home before hospitalization."},{"linkId":"Section-38/15A","prefix":"15A","text":"Admit From","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.14","description":"From where was the patient admitted?"},{"linkId":"Section-38/16A","prefix":"16A","text":"Pre-hospital Living Setting. Use codes from {Admit From}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.15","description":"The pre-hospital living setting of the patient is determined by using codes from the 'Admit From' category."},{"linkId":"Section-38/1","prefix":"1","text":"{Facility/Provider} Information","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0"}],"id":"item.1.item.16","description":"The form contains a section for the patient to provide information about the facility or provider they are connected with.\n"},{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0","description":"What is the name of the facility or provider for the patient?"},{"linkId":"Section-38/5B","prefix":"5B","text":"{Patient/Resident} Identification Number","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.17","description":"What is the patient's or resident's identification number?"},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}],"id":"item.1.item.18","description":"The patient should check all the boxes that apply to their race or ethnicity."},{"linkId":"Section-41","code":[{"system":"http://loinc.org","code":"87415-6","display":"IRF-PAI v3.0 - Medical Info [CMS Assessment]"}],"text":"Medical Information","type":"group","readOnly":true,"item":[{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Height (in inches). Record most recent height measure since {admission}","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"Weight (in pounds). Base weight on most recent measure in last {specify time period in days}; measure weight consistently, according to standard {facility/setting} practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer","repeats":false,"readOnly":false,"maxLength":3,"id":"item.2.item.1"},{"linkId":"Section-41/21A","prefix":"21A","text":"Impairment Group - Admission: Condition requiring admission to rehabilitation; code according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.2.item.2"},{"linkId":"Section-41/23","prefix":"23","text":"Date of Onset of Impairment","type":"open-choice","repeats":false,"readOnly":false,"id":"item.2.item.3"},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Are there any arthritis conditions recorded in items {impairment group, etiologic diagnosis, or comorbid conditions} that meet all the regulatory requirements for {IRF} classification","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.2.item.4"},{"linkId":"Section-41/22","prefix":"22","text":"Etiologic Diagnosis: (Use ICD codes to indicate the etiologic problem that led to the condition for which the {patient/resident} is receiving rehabilitation)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0"},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1"},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2"}],"id":"item.2.item.5"},{"linkId":"Section-41/24","prefix":"24","text":"Comorbid Conditions. Use ICD codes to enter comorbid medical conditions","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8"},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18"},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21"},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24"}],"id":"item.2.item.6"},{"linkId":"Section-41/21","prefix":"21","text":"Impairment group","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0"}],"id":"item.2.item.7"}],"id":"item.2","description":"The form is requesting the patient's medical information."},{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Height (in inches). Record most recent height measure since {admission}","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"The form asks for the patient's height in inches and requests the most recent measurement since their admission."},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"Weight (in pounds). Base weight on most recent measure in last {specify time period in days}; measure weight consistently, according to standard {facility/setting} practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer","repeats":false,"readOnly":false,"maxLength":3,"id":"item.2.item.1","description":"The patient's weight, in pounds, should be based on the most recent measurement taken within the specified time period in days. It's important to measure the patient's weight consistently, adhering to the standard practice of the facility or setting. For instance, this could be done in the morning after voiding, before a meal, with shoes off, and so on."},{"linkId":"Section-41/21A","prefix":"21A","text":"Impairment Group - Admission: Condition requiring admission to rehabilitation; code according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.2.item.2","description":"The impairment group on the admission form refers to the condition that required the patient's admission to rehabilitation, which should be coded according to Appendix A."},{"linkId":"Section-41/23","prefix":"23","text":"Date of Onset of Impairment","type":"open-choice","repeats":false,"readOnly":false,"id":"item.2.item.3","description":"When did the patient's impairment begin?"},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Are there any arthritis conditions recorded in items {impairment group, etiologic diagnosis, or comorbid conditions} that meet all the regulatory requirements for {IRF} classification","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.2.item.4","description":"Does the patient have any arthritis conditions recorded in the impairment group, etiologic diagnosis, or comorbid conditions that meet all the regulatory requirements for Inpatient Rehabilitation Facility (IRF) classification?"},{"linkId":"Section-41/22","prefix":"22","text":"Etiologic Diagnosis: (Use ICD codes to indicate the etiologic problem that led to the condition for which the {patient/resident} is receiving rehabilitation)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0"},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1"},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2"}],"id":"item.2.item.5","description":"The etiologic diagnosis requires the use of ICD codes to indicate the underlying problem that led to the condition for which the patient is receiving rehabilitation."},{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0","description":"The form for the patient includes a section labeled \"Etiologic Diagnosis A\"."},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1","description":"The form for the patient includes a section labeled \"Etiologic Diagnosis B\"."},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2","description":"The form asks for the patient's etiologic diagnosis C."},{"linkId":"Section-41/24","prefix":"24","text":"Comorbid Conditions. Use ICD codes to enter comorbid medical conditions","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8"},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18"},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21"},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24"}],"id":"item.2.item.6","description":"The patient is instructed to use ICD codes to enter their comorbid medical conditions under the section labeled \"Comorbid Conditions.\""},{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0","description":"Does the patient have a comorbid condition A?"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1","description":"Does the patient have Comorbid Condition B?"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2","description":"Does the patient have Comorbid Condition C?"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3","description":"Does the patient have any comorbid condition D?"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4","description":"Does the patient have a comorbid condition E?"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5","description":"Does the patient have a comorbid condition F?"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6","description":"Does the patient have comorbid condition G?"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7","description":"Does the patient have a comorbid condition H?"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8","description":"Does the patient have a comorbid condition? If yes, please specify."},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9","description":"Does the patient have Comorbid Condition J?"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10","description":"Does the patient have a comorbid condition K?"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11","description":"Does the patient have any comorbid condition L?"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12","description":"Does the patient have a comorbid condition M?"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13","description":"Does the patient have a comorbid condition N?"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14","description":"Does the patient have any comorbid conditions?"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15","description":"Does the patient have a comorbid condition P?"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16","description":"Does the patient have a comorbid condition?"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17","description":"Does the patient have a comorbid condition R?"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18","description":"The form asks if the patient has any comorbid conditions."},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19","description":"Does the patient have a comorbid condition T?"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20","description":"Does the patient have a comorbid condition U?"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21","description":"Does the patient have a comorbid condition V? Please indicate yes or no."},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22","description":"Does the patient have any comorbid condition W?"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23","description":"Does the patient have a comorbid condition X?"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24","description":"Does the patient have comorbid condition Y?"},{"linkId":"Section-41/21","prefix":"21","text":"Impairment group","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0"}],"id":"item.2.item.7","description":"What is the patient's impairment group?"},{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0","description":"What is the impairment group upon admission for the patient?"},{"linkId":"Section-40","code":[{"system":"http://loinc.org","code":"85401-8","display":"IRF-PAI - Payer information [CMS Assessment]"}],"text":"Payer Information","type":"group","readOnly":true,"item":[{"linkId":"Section-40/20","prefix":"20","text":"Payment Source","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0"},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1"}],"id":"item.3.item.0"}],"id":"item.3","description":"The form requires the patient's payer information."},{"linkId":"Section-40/20","prefix":"20","text":"Payment Source","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0"},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1"}],"id":"item.3.item.0","description":"The payment source for the patient is being determined."},{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0","description":"The primary source of information regarding the patient's health condition is the patient themselves."},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1","description":"The form for the patient includes a section titled \"Secondary Source.\""},{"linkId":"Section-2","code":[{"system":"http://loinc.org","code":"88522-8","display":"IRF-PAI v2.0 - Hearing, speech, and vision - admission [CMS Assessment]"}],"text":"Section B: Hearing, Speech, and Vision","type":"group","readOnly":true,"item":[{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}],"id":"item.4.item.0"},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}],"id":"item.4.item.1"}],"id":"item.4","description":"In Section B of the form, the patient's hearing, speech, and vision capabilities are assessed."},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}],"id":"item.4.item.0","description":"The patient's expression of ideas and wants, considering both verbal and non-verbal expression and excluding language barriers, should be evaluated. Does the patient often communicate their ideas and desires clearly? The answer could be 'Always', 'Often', 'Sometimes', 'Rarely', or 'Never'."},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}],"id":"item.4.item.1","description":"Does the patient understand both verbal and non-verbal content with the use of a hearing aid or device, if used, while excluding any language barriers?"},{"linkId":"Section-3","code":[{"system":"http://loinc.org","code":"88524-4","display":"IRF-PAI v2.0 - Cognitive patterns - admission [CMS Assessment]"}],"text":"Section C: Cognitive Patterns","type":"group","readOnly":true,"item":[{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all {patients/residents}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.5.item.0"},{"linkId":"Section-3/C0200","prefix":"C0200","text":"Repetition of Three Words - Ask {patient/resident}: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}],"id":"item.5.item.1"},{"linkId":"Section-3/C0500","prefix":"C0500","text":"BIMS Summary Score. Add scores for {Brief Interview for Mental Status questions} and fill in total score (00-15). Enter 99 if the {patient/resident} was unable to complete the interview","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.2"},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the Staff Assessment for Mental Status be Conducted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes ({patient/resident} was unable to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}],"id":"item.5.item.3"},{"linkId":"Section-3/C0300","prefix":"C0300","text":"BIMS: Temporal Orientation (orientation to year, month, and day)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0"},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1"},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2"}],"id":"item.5.item.4"},{"linkId":"Section-3/C0400","prefix":"C0400","text":"Recall. Ask {patient/resident}: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0"},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1"},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2"}],"id":"item.5.item.5"},{"linkId":"Section-3/C0900","prefix":"C0900","text":"Memory/Recall Ability: Check all that the {patient/resident} was normally able to recall","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above were recalled"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}],"id":"item.5.item.6"}],"id":"item.5","description":"In Section C of the form, the patient's cognitive patterns are assessed."},{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all {patients/residents}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.5.item.0","description":"Should a Brief Interview for Mental Status be conducted? It is suggested to attempt to conduct the interview with all patients or residents."},{"linkId":"Section-3/C0200","prefix":"C0200","text":"Repetition of Three Words - Ask {patient/resident}: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}],"id":"item.5.item.1","description":"The form asks the patient, \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" The number of words repeated after the first attempt is then recorded by the medical professional."},{"linkId":"Section-3/C0500","prefix":"C0500","text":"BIMS Summary Score. Add scores for {Brief Interview for Mental Status questions} and fill in total score (00-15). Enter 99 if the {patient/resident} was unable to complete the interview","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.2","description":"The BIMS Summary Score should be calculated by adding the scores for the Brief Interview for Mental Status questions and filling in the total score, which ranges from 00 to 15. If the patient or resident was unable to complete the interview, the score to be entered should be 99."},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the Staff Assessment for Mental Status be Conducted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes ({patient/resident} was unable to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}],"id":"item.5.item.3","description":"Should the staff assessment for the patient's mental status be conducted?"},{"linkId":"Section-3/C0300","prefix":"C0300","text":"BIMS: Temporal Orientation (orientation to year, month, and day)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0"},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1"},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2"}],"id":"item.5.item.4","description":"The patient's BIMS assessment includes a temporal orientation evaluation, which evaluates their orientation to the current year, month, and day."},{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0","description":"The form asks the patient or resident, \"Please tell me what year it is right now.\" They are able to report the correct year."},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1","description":"The form asks the patient or resident, \"What month are we in right now?\" The patient or resident should be able to report the correct month."},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2","description":"Ask the patient or resident: \"What day of the week is today?\" They should be able to report the correct day of the week."},{"linkId":"Section-3/C0400","prefix":"C0400","text":"Recall. Ask {patient/resident}: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0"},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1"},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2"}],"id":"item.5.item.5","description":"The doctor asks the patient, \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If the patient is unable to remember a word, the doctor gives a cue, such as 'something to wear', 'a color', or 'a piece of furniture', for that particular word."},{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0","description":"The patient is able to recall the word \"sock\"."},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1","description":"The patient is able to recall the color \"blue\"."},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2","description":"Is the patient able to recall \"bed\"?"},{"linkId":"Section-3/C0900","prefix":"C0900","text":"Memory/Recall Ability: Check all that the {patient/resident} was normally able to recall","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above were recalled"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}],"id":"item.5.item.6","description":"The patient's or resident's ability to recall normally should be assessed. Please check all that apply."},{"linkId":"Section-37","code":[{"system":"http://loinc.org","code":"88482-5","display":"Functional abilities and goals - admission [CMS Assessment]"}],"text":"Section GG: Functional Abilities and Goals","type":"group","readOnly":true,"item":[{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.0"},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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If managing an ostomy, include wiping the opening but not managing equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.13"},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.14"},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.28"},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the {patient/resident} use a wheelchair and/or scooter? - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.6.item.29"},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.30"},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.31"},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.32"},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.33"},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.34"},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.35"},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.36"},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.37"},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.45"},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.46"},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.47"},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.48"},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"4 steps: The ability to go up and down four steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.49"},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.50"},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.51"},{"linkId":"Section-37/GG0100","prefix":"GG0100","text":"Prior Functioning: Everyday Activities. Indicate the {patient's/resident's} usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0"},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1"},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2"},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3"}],"id":"item.6.item.52"},{"linkId":"Section-37/GG0130","prefix":"GG0130","text":"Self-Care.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0"},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1"}],"id":"item.6.item.53"},{"linkId":"Section-37/GG0170","prefix":"GG0170","text":"Mobility.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0"},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1"}],"id":"item.6.item.54"},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Prior Device Use. Indicate devices and aids used by the {patient/resident} prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.6.item.55"}],"id":"item.6","description":"In Section GG of the form, the patient's functional abilities and goals are documented."},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.0","description":"The question for the patient or resident is about their eating ability. Specifically, can they use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them? This is in reference to their performance upon admission."},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.1","description":"The form asks about the patient's oral hygiene, specifically their ability to use suitable items to clean their teeth. It also inquires if they have dentures and if so, their ability to insert and remove them from the mouth, as well as manage denture soaking and rinsing with the use of equipment. This is relevant to their admission performance."},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.2","description":"The form asks about the patient's ability to maintain perineal hygiene and adjust their clothes before and after voiding or having a bowel movement. If the patient is managing an ostomy, it includes the task of wiping the opening but not managing the equipment. This is pertaining to their performance upon admission."},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.3","description":"The discharge goal for the patient is to have the ability to use suitable utensils in order to bring food and/or liquid to their mouth and to be able to swallow food and/or liquid once the meal is placed before them."},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.4","description":"The form inquires about the patient's oral hygiene: their ability to use suitable items to clean their teeth. It also asks if the patient has dentures and if so, it assesses their ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with the use of equipment. The goal is to prepare the patient for discharge."},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.5","description":"The discharge goal for the patient is related to toileting hygiene, which refers to their ability to maintain perineal hygiene, adjust clothing before and after voiding or having a bowel movement. If they are managing an ostomy, this also includes wiping the opening, but not managing the equipment."},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.6","description":"The form asks about the patient's ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed, as part of their admission performance."},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.7","description":"The form asks about the patient's admission performance regarding their ability to move from sitting on the side of the bed to lying flat on the bed."},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.8","description":"The form is asking about the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. This is in reference to their admission performance."},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.9","description":"The discharge goal for the patient is to acquire the ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed."},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.10","description":"The discharge goal for the patient is to have the ability to move from sitting on the side of the bed to lying flat on the bed."},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.11","description":"The discharge goal for the patient is to have the ability to move from lying on their back to sitting on the side of the bed without any back support."},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.12","description":"The form asks the patient about their ability to come to a standing position from sitting in a chair, a wheelchair, or on the side of the bed, and requests them to rate their admission performance."},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.13","description":"The form is asking about the patient's ability to transfer to and from a bed to a chair or wheelchair. It is inquiring about their admission performance."},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.14","description":"The form asks about the patient's ability to transfer to and from a toilet or commode on their own as it pertains to their performance upon admission."},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.15","description":"The question on the form asks about the patient's admission performance in relation to their ability to walk. Specifically, it inquires whether, once standing, the patient can walk at least 10 feet in a room, corridor, or similar space."},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.16","description":"Once standing, the patient has the ability to walk at least 50 feet and make two turns as part of their admission performance."},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.17","description":"The form inquires about the patient's capability to walk at least 150 feet in a corridor or similar space once they are standing. This is referred to as the \"Admission Performance\" aspect."},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.18","description":"Once the patient is seated in the wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. This is a requirement for admission performance."},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.19","description":"The admission performance form includes a question regarding the patient's ability, once seated in a wheelchair or scooter, to wheel at least 150 feet in a corridor or similar space."},{"linkId":"Section-37/GG0170K3","prefix":"GG0170K3","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Discharge Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.20","description":"The form asks about the patient's ability to walk at least 150 feet in a corridor or similar space once they are standing, with the label of \"Discharge Performance\"."},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.21","description":"The discharge goal for the patient is to develop the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed."},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.22","description":"The form asks about the patient's ability to transfer themselves to and from a bed to a chair or wheelchair. The discharge goal is to evaluate this capability."},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.23","description":"The discharge goal for the patient refers to their ability to independently get on and off a toilet or commode."},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.24","description":"The question on the form is asking about the patient's ability, once standing, to walk at least 10 feet in a room, corridor, or similar space. The goal is that the patient should be able to do this upon discharge."},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.25","description":"The label is asking about the patient's ability, once standing, to walk a minimum of 50 feet and make two turns. The goal is to achieve this by the time of discharge."},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.26","description":"The form asks if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The response options for this question are 'discharge goal'."},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.27","description":"The discharge goal for the patient is to be able to wheel at least 50 feet and make two turns once seated in a wheelchair or scooter."},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.28","description":"The discharge goal for the patient is to gain the ability to wheel at least 150 feet in a corridor or similar space once seated in a wheelchair or scooter."},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the {patient/resident} use a wheelchair and/or scooter? - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.6.item.29","description":"Does the patient or resident use a wheelchair and/or scooter upon admission?"},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.30","description":"The form is asking the patient to indicate the type of wheelchair or scooter they use upon admission."},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.31","description":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission."},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.32","description":"The form asks about the patient's ability to shower or bathe themselves, which includes tasks such as washing, rinsing, and drying themselves, but does not include washing their back and hair, nor transferring in and out of the tub or shower. The question relates to their performance upon admission."},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.33","description":"The admission form inquires about the patient's ability to dress and undress above the waist, including handling fasteners if applicable, in the section labeled \"Upper body dressing.\""},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.34","description":"On the admission performance form, there is a question about the patient's ability to dress and undress below the waist, including handling fasteners. This does not include dealing with footwear."},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.35","description":"Does the patient have the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable? Please evaluate their performance upon admission."},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.36","description":"On the admission form, it asks about the patient's ability to transfer in and out of a car or van on the passenger side, without including the ability to open or close the door or fasten the seat belt."},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.37","description":"The form asks if the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, either indoors or outdoors. This is in reference to their admission performance."},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.38","description":"The form asks about the patient's ability to go up and down a curb and/or up and down one step in regards to their admission performance."},{"linkId":"Section-37/GG0170N1","prefix":"GG0170N1","text":"4 steps: The ability to go up and down four steps with or without a rail. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.39","description":"The form asks about the patient's ability to go up and down four steps with or without a rail in terms of admission performance."},{"linkId":"Section-37/GG0170O1","prefix":"GG0170O1","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.40","description":"The form asks whether the patient has the ability to go up and down 12 steps with or without a rail as part of their admission performance."},{"linkId":"Section-37/GG0170P1","prefix":"GG0170P1","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.41","description":"The form asks about the patient's admission performance in terms of their ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor."},{"linkId":"Section-37/GG0130E2","prefix":"GG0130E2","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.42","description":"The discharge goal for the patient is to be able to shower or bathe themselves. This means the patient should have the ability to wash, rinse, and dry themselves, excluding washing of the back and hair. It does not include transferring in or out of the tub or shower."},{"linkId":"Section-37/GG0130F2","prefix":"GG0130F2","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.43","description":"The discharge goal for the patient is to be able to dress and undress above the waist, which includes handling any fasteners, if applicable, on their own."},{"linkId":"Section-37/GG0130G2","prefix":"GG0130G2","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.44","description":"The discharge goal for the patient is to be able to independently dress and undress their lower body, below the waist, including handling fasteners, but not including footwear."},{"linkId":"Section-37/GG0130H2","prefix":"GG0130H2","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.45","description":"The form asks about the patient's ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable, and what the discharge goal for this ability is."},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.46","description":"The discharge goal for the patient is to have the ability to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten their seat belt."},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.47","description":"The form asks if the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoor or outdoor, with the discharge goal being the endpoint."},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.48","description":"The question on the form asks about the patient's ability to go up and down a curb and/or up and down one step. The label for this section is \"Discharge Goal\"."},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"4 steps: The ability to go up and down four steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.49","description":"The discharge goal for the patient is to have the ability to go up and down four steps with or without a rail."},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.50","description":"The discharge goal for the patient is to develop the ability to go up and down 12 steps with or without the use of a rail."},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.51","description":"The discharge goal for the patient is to have the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor."},{"linkId":"Section-37/GG0100","prefix":"GG0100","text":"Prior Functioning: Everyday Activities. Indicate the {patient's/resident's} usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0"},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1"},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2"},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3"}],"id":"item.6.item.52","description":"Please indicate the patient's usual ability with everyday activities prior to their current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0","description":"Please code the patient's or resident's need for assistance with bathing, dressing, using the toilet, and eating prior to their current illness, exacerbation, or injury for the Self-Care section."},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1","description":"The form requests the code for the patient's or resident's need for assistance with walking from room to room, with or without a device such as a cane, crutch, or walker, prior to the current illness, exacerbation, or injury to determine their level of indoor mobility and ambulation."},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2","description":"The form asks to code the patient's or resident's need for assistance with internal or external stairs, with or without a device such as a cane, crutch, or walker, prior to the current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3","description":"The form asks to code the patient's or resident's need for assistance with planning regular tasks, such as shopping or remembering to take medication, prior to their current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0130","prefix":"GG0130","text":"Self-Care.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0"},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1"}],"id":"item.6.item.53","description":"The patient is capable of self-care."},{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0","description":"For the category of Self-Care, please code the patient's usual performance at the time of admission for each activity using the 6-point scale. If the activity was not attempted at the time of admission, please code the reason."},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1","description":"Please code the patient's or resident's self-care discharge goals using the 6-point scale. The use of codes 07, 09, 10, or 88 is permissible to code the discharge goals."},{"linkId":"Section-37/GG0170","prefix":"GG0170","text":"Mobility.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0"},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1"}],"id":"item.6.item.54","description":"The patient's mobility status is being assessed."},{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0","description":"For the section on mobility, please code the patient's or resident's usual performance at the time of admission for each activity using the 6-point scale. If a certain activity was not attempted at the time of admission, code the reason."},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1","description":"The form instructs the user to code the patient's or resident's discharge goals using the 6-point scale. The use of codes 07, 09, 10, or 88 is permissible to code the discharge goals."},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Prior Device Use. Indicate devices and aids used by the {patient/resident} prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.6.item.55","description":"Please indicate the devices and aids that the patient or resident used prior to their current illness, exacerbation, or injury. Check all that apply."},{"linkId":"Section-8","code":[{"system":"http://loinc.org","code":"83237-8","display":"Bladder and bowel [CMS Assessment]"}],"text":"Section H: Bladder and Bowel","type":"group","readOnly":true,"item":[{"linkId":"Section-8/H0400","prefix":"H0400","text":"Bowel Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}],"id":"item.7.item.0"},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Bladder Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}],"id":"item.7.item.1"}],"id":"item.7","description":"In section H of the form, the patient's bladder and bowel conditions are addressed."},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Bowel Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}],"id":"item.7.item.0","description":"Please select the one category that best describes the bowel continence of the patient or resident."},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Bladder Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}],"id":"item.7.item.1","description":"Please select the one category that best describes the patient's or resident's bladder continence."},{"linkId":"Section-9","code":[{"system":"http://loinc.org","code":"83264-2","display":"IRF-PAI - Active diagnoses [CMS Assessment]"}],"text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0000","prefix":"I0000","text":"Active Diagnoses in the last 7 days: Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.8.item.0"}],"id":"item.8","description":"In Section I of the form, the patient's active diagnoses are listed."},{"linkId":"Section-9/I0000","prefix":"I0000","text":"Active Diagnoses in the last 7 days: Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.8.item.0","description":"The patient has been asked to indicate all of their active diagnoses from the last 7 days on the form. They should check all that apply. The diagnoses provided in parentheses are just examples and should not be considered as an all-inclusive list."},{"linkId":"Section-10","code":[{"system":"http://loinc.org","code":"83273-3","display":"IRF-PAI - Health conditions - admission [CMS Assessment]"}],"text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J1750","prefix":"J1750","text":"History of Falls: Has the {patient/resident} had two or more falls in the past year or any fall with injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.0"},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Prior Surgery. Did the {patient/resident} have major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.1"}],"id":"item.9","description":"In Section J of the form, the patient's health conditions are being evaluated."},{"linkId":"Section-10/J1750","prefix":"J1750","text":"History of Falls: Has the {patient/resident} had two or more falls in the past year or any fall with injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.0","description":"Does the patient or resident have a history of having two or more falls in the past year, or any fall that resulted in injury in the past year?"},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Prior Surgery. Did the {patient/resident} have major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.1","description":"Did the patient or resident have any major surgery during the 100 days prior to their admission?"},{"linkId":"Section-11","code":[{"system":"http://loinc.org","code":"83244-4","display":"IRF-PAI v2.0 - Swallowing/nutritional status - admission [CMS Assessment]"}],"text":"Section K: Swallowing/Nutritional Status","type":"group","readOnly":true,"item":[{"linkId":"Section-11/K0110","prefix":"K0110","text":"Swallowing/Nutritional Status. Indicate the {patient's/resident's} usual ability to swallow: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Regular food - Solids and liquids swallowed safely without supervision or modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Modified food consistency/supervision - {Patient/Resident} requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Tube/parenteral feeding - Tube/parenteral feeding used wholly or partially as a means of sustenance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}],"id":"item.10.item.0"}],"id":"item.10","description":"In Section K of the form, the patient's swallowing and nutritional status is assessed."},{"linkId":"Section-11/K0110","prefix":"K0110","text":"Swallowing/Nutritional Status. Indicate the {patient's/resident's} usual ability to swallow: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Regular food - Solids and liquids swallowed safely without supervision or modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Modified food consistency/supervision - {Patient/Resident} requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Tube/parenteral feeding - Tube/parenteral feeding used wholly or partially as a means of sustenance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}],"id":"item.10.item.0","description":"Please indicate the patient's usual ability to swallow regarding their swallowing or nutritional status. Check all that apply."},{"linkId":"Section-13","code":[{"system":"http://loinc.org","code":"85055-2","display":"IRF-PAI v3.0, LCDS v4.00 - Skin conditions - admission [CMS Assessment]"}],"text":"Section M: Skin Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-13/M0210","prefix":"M0210","text":"Unhealed Pressure Ulcers/Injuries. Does this {patient/resident} have one or more unhealed pressure ulcers/injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.11.item.0"},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"Number of Stage 2 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.1"},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"Number of Stage 3 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.2"},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"Number of Stage 4 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.3"},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.4"},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.5"},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.6"},{"linkId":"Section-13/M0300","prefix":"M0300","text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0"},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1"},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2"},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3"},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4"},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5"},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6"}],"id":"item.11.item.7"},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"Number of Stage 1 pressure injuries","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.8"}],"id":"item.11","description":"In Section M of the form, the patient's skin conditions are addressed."},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Unhealed Pressure Ulcers/Injuries. Does this {patient/resident} have one or more unhealed pressure ulcers/injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.11.item.0","description":"Does this patient or resident have one or more unhealed pressure ulcers or injuries?"},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"Number of Stage 2 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.1","description":"The patient has how many Stage 2 pressure ulcers?"},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"Number of Stage 3 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.2","description":"How many stage 3 pressure ulcers does the patient have?"},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"Number of Stage 4 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.3","description":"The patient has a certain number of Stage 4 pressure ulcers."},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.4","description":"How many unstageable pressure ulcers/injuries does the patient have due to a non-removable dressing/device?"},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.5","description":"How many unstageable pressure ulcers does the patient have due to coverage of the wound bed by slough and/or eschar?"},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.6","description":"The patient has a certain number of unstageable pressure injuries that present as deep tissue injury."},{"linkId":"Section-13/M0300","prefix":"M0300","text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0"},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1"},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2"},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3"},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4"},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5"},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6"}],"id":"item.11.item.7","description":"The form is asking for the current number of unhealed pressure ulcers/injuries at each stage that the patient has."},{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0","description":"The patient's condition is at Stage 1, where there is intact skin with non-blanchable redness of a localized area, usually over a bony prominence. It is noted that darkly pigmented skin may not exhibit visible blanching. In such cases, dark skin tones may only appear with persistent blue or purple hues."},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1","description":"The patient is at stage 2, which indicates a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. This may also present as an intact or open/ruptured blister."},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2","description":"The patient is at stage 3, which indicates full thickness tissue loss. At this stage, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but it does not obscure the depth of tissue loss. This stage may also include undermining and tunneling."},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3","description":"The patient has stage 4 skin integrity, characterized by full thickness tissue loss with exposed bone, tendon, or muscle. There may be slough or eschar present on some parts of the wound bed, and the condition often includes undermining and tunneling."},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4","description":"The patient has an unstageable condition due to a non-removable dressing or device, although the exact stage is known but cannot be identified because of the non-removable dressing or device."},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5","description":"The patient has a known, but unstageable wound due to the coverage of the wound bed by slough and/or eschar."},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6","description":"The patient has an unstageable deep tissue injury."},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"Number of Stage 1 pressure injuries","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.8","description":"How many Stage 1 pressure injuries does the patient have?"},{"linkId":"Section-14","code":[{"system":"http://loinc.org","code":"88872-7","display":"IRF-PAI v2.0 - Medications - admission [CMS Assessment]"}],"text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/N2001","prefix":"N2001","text":"Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}],"id":"item.12.item.0"},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Medication Follow-up. Did the {facility/setting} contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.12.item.1"}],"id":"item.12","description":"In Section N of the form, the medications that the patient is currently taking are listed."},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}],"id":"item.12.item.0","description":"Did a complete drug regimen review identify any potential clinically significant medication issues for the patient? The options are 'Yes', 'No', and 'Not applicable'."},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Medication Follow-up. Did the {facility/setting} contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.12.item.1","description":"Did the facility or setting in question contact a physician or a physician's designee by midnight of the following calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues related to the patient?"},{"linkId":"Section-15","code":[{"system":"http://loinc.org","code":"83261-8","display":"IRF-PAI v3.0 - Special treatments, procedures, and programs - admission [CMS Assessment]"}],"text":"Section O: Special Treatments, Procedures, and Programs","type":"group","readOnly":true,"item":[{"linkId":"Section-15/O0100","prefix":"O0100","text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that were performed","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}],"id":"item.13.item.0"}],"id":"item.13","description":"In Section O of the form, the patient is asked about special treatments, procedures, and programs they may have undergone."},{"linkId":"Section-15/O0100","prefix":"O0100","text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that were performed","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}],"id":"item.13.item.0","description":"Please indicate all of the special treatments, procedures, and programs that were performed on the patient."},{"linkId":"Section-19","text":"Section Z: Assessment Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-19/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0"},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1"},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2"},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3"},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4"},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5"},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6"},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7"},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8"},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9"},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10"},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11"}],"id":"item.14.item.0"}],"id":"item.14","description":"In Section Z of the form, the assessment administration for the patient is carried out."},{"linkId":"Section-19/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0"},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1"},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2"},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3"},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4"},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5"},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6"},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7"},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8"},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9"},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10"},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11"}],"id":"item.14.item.0","description":"The signature of the person who completed the assessment for the patient is required."},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0","description":"The patient filled out the Signature, Title, Sections, and Date Section Completed A on the form."},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1","description":"The patient needs to provide their signature, title, and date for the sections they have completed in Section B."},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2","description":"The patient needs to complete the signature, title, and sections of the form, and indicate the date the section C was completed."},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3","description":"The patient is required to provide their signature, title, and date the sections that have been completed in Section D."},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4","description":"The patient needs to provide their signature, title, and the sections they have completed, along with the date they finished section E."},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5","description":"The patient's form contains a section for the signature, title, and sections, and also records the date the section was completed."},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6","description":"The patient is required to provide their signature, title, fill in the sections, and add the date the section was completed on form G."},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7","description":"The patient's form contains sections for signature, title, and date, which need to be completed. In section H, the form is completed."},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8","description":"The section titled \"Signature, Title, Sections, Date Section Completed I\" requires the patient's signature, their title, and the date on which they completed the section."},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9","description":"The patient completed the signature, title, and sections on the form, and dated it on section J."},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10","description":"The patient is required to provide their signature and title in the specified sections, and the date when they completed the form."},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11","description":"The patient must provide their signature and title, complete all sections, and include the date that they completed the form."},{"linkId":"Section-49","text":"Therapy Information","type":"group","readOnly":true,"item":[{"linkId":"Section-49/O0401","prefix":"O0401","text":"Week 1: total number of minutes provided","type":"text","repeats":false,"readOnly":false,"item":[{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0"}],"id":"item.15.item.0"}],"id":"item.15","description":"The patient's therapy information is required."},{"linkId":"Section-49/O0401","prefix":"O0401","text":"Week 1: total number of minutes provided","type":"text","repeats":false,"readOnly":false,"item":[{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0"}],"id":"item.15.item.0","description":"In the first week, what was the total number of minutes of care provided to the patient?"},{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0","description":"Does the patient require physical therapy?"},null],"_id":"e5vd7FzpqFgN9QLis"} {"id":"fasi","responseType":"QuestionnaireResponse","status":"draft","authored":"2024-04-27T18:21:32.181Z","item":[{"linkId":"Section-37/GG0175A","prefix":"GG0175A","text":"Does the patient or resident use a manual wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0175F","prefix":"GG0175F","text":"Does the patient or resident use a motorized wheelchair and/or scooter?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0125B1","prefix":"GG0125B1","text":"Does the patient use an assistive device such as a standard folding walker?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170HH","prefix":"GG0170HH","text":"Does the patient or resident have the ability to walk?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No, and walking goal is not indicated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA31067-4","display":"No, and walking goal is not indicated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"No, and walking is indicated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA31068-2","display":"No, and walking goal is indicated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-6/F0900A1","prefix":"F0900A1","text":"Please identify the usual living arrangement of the patient or resident during the past three days.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident} lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30925-4","display":"Person lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident} lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30926-2","display":"Person lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident} lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30927-0","display":"Person lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident} does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30928-8","display":"Person does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident} was in a medical facility."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30929-6","display":"Person was in a medical facility."}}]},{"linkId":"Section-37/GG0125B","prefix":"GG0125B","text":"Does the patient use an assistive device such as a walker?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Z","prefix":"GG0125Z","text":"Does the patient use an assistive device other than the ones previously mentioned?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125A","prefix":"GG0125A","text":"The patient uses an assistive device, specifically a cane or a crutch.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125AA","prefix":"GG0125AA","text":"In the past month, has the patient used, or expressed or demonstrated a need for an assistive device?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}}]},{"linkId":"Section-6/F0910A","prefix":"F0910A","text":"Does the patient or resident have assistance in their home? The options are \"Yes\" or \"No\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170X7","prefix":"GG0170X7","text":"The patient's usual performance indicates their ability to walk across a street before the light turns red.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170E7","prefix":"GG0170E7","text":"The form inquires about the patient's usual performance in terms of their ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170J7","prefix":"GG0170J7","text":"Does the patient have the ability, once standing, to walk at least 50 feet and make two turns as part of their usual performance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920E1","prefix":"F0920E1","text":"Has the patient paid for medical procedures or treatments, such as changing wound dressings or home exercise programs?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920B2","prefix":"F0920B2","text":"Does the patient require mobility assistance, such as help with bed mobility, transfers, ambulating, or wheeling, and is this assistance unpaid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170K7","prefix":"GG0170K7","text":"Once the patient is standing, they should have the ability to walk at least 150 feet in a corridor or similar space. The usual performance is evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170F8","prefix":"GG0170F8","text":"The form inquires about the patient's ability to transfer to and from a toilet or commode, asking whether their performance is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170D7","prefix":"GG0170D7","text":"Does the patient typically have the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920H1","prefix":"F0920H1","text":"Does the individual advocate or facilitate the patient's participation in appropriate medical care, for example, providing transportation to or from appointments? The options for this are either paid or unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170M7","prefix":"GG0170M7","text":"The form asks about the patient's usual performance in the ability to go up and down a curb and/or up and down one step.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170W8","prefix":"GG0170W8","text":"The patient's ability to walk for 15 minutes without stopping or resting, like through a department store or supermarket, is the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170B7","prefix":"GG0170B7","text":"The form asks about the patient's usual ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130F7","prefix":"GG0130F7","text":"The form asks about the patient's usual performance in terms of their ability to dress and undress their upper body, including handling fasteners if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170X8","prefix":"GG0170X8","text":"The form asks the patient about their ability to walk across a street before the light turns red, with the most dependent performance as an answer choice.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170N7","prefix":"GG0170N7","text":"The form is asking about the patient's usual performance in regards to their ability to go up and down four steps, with or without using a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175B8","prefix":"GG0175B8","text":"Once seated in their manual wheelchair, the patient has the ability to wheel at least 50 feet and make two turns, indicating a most dependent performance level.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920F1","prefix":"F0920F1","text":"Does the patient manage their equipment, for example, oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies, and is it paid for?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920D2","prefix":"F0920D2","text":"Does the patient administer their medication themselves (for example, oral, inhaled, or injectable medications) without any paid assistance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0910B2","prefix":"F0910B2","text":"Please indicate the level of both paid and unpaid assistance in the patient's or resident's home during the past month. The level of assistance was unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No assistance received"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12345-7","display":"No assistance received"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Occasional/short-term assistance"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30934-6","display":"Occasional/short term assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Regular night-time"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30935-3","display":"Regular night-time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Regular daytime"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12164-2","display":"Regular daytime"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Around the clock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12163-4","display":"Around the clock"}}]},{"linkId":"Section-37/GG0130H7","prefix":"GG0130H7","text":"The form asks the patient to evaluate their usual performance in putting on and taking off socks, shoes, or other footwear appropriate for safe mobility. This includes handling fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170O8","prefix":"GG0170O8","text":"The form asks the patient to assess their ability to go up and down 12 steps with or without a rail, with the most dependent performance being the possible response.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130G7","prefix":"GG0130G7","text":"The form asks about the patient's usual performance in their ability to dress and undress below the waist, including fasteners, excluding footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170M8","prefix":"GG0170M8","text":"The form asks about the patient's ability to go up and down a curb and/or up and down one step. The patient's performance is most dependent in this activity.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175G8","prefix":"GG0175G8","text":"Once seated in their motorized wheelchair or scooter, the patient has the ability to wheel at least 50 feet and make two turns. However, their performance indicates that they are most dependent on this form of mobility.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920H2","prefix":"F0920H2","text":"Does the person facilitate or advocate for the patient's participation in appropriate medical care, for instance, by transporting them to or from appointments, without any charge?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0910B1","prefix":"F0910B1","text":"Please indicate the level of both paid and unpaid assistance in the patient's or resident's home during the past month. The choices are \"Paid\", \"Unpaid\", or \"Both Paid and Unpaid\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No assistance received"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12345-7","display":"No assistance received"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Occasional/short-term assistance"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30934-6","display":"Occasional/short term assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Regular night-time"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30935-3","display":"Regular night-time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Regular daytime"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12164-2","display":"Regular daytime"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Around the clock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12163-4","display":"Around the clock"}}]},{"linkId":"Section-37/GG0175B7","prefix":"GG0175B7","text":"The form asks about the patient's ability to wheel at least 50 feet and make two turns once seated in a manual wheelchair, assessing their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170I7","prefix":"GG0170I7","text":"The form asks about the patient's usual performance in terms of their ability to walk at least 10 feet once standing, whether it be in a room, corridor, or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170L7","prefix":"GG0170L7","text":"The form asks about the patient's usual performance in the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, both indoors and outdoors.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170U8","prefix":"GG0170U8","text":"The form asks about the patient's ability to walk from one room to another, maneuver around furniture, and navigate other obstacles indoors. The label classifies the patient's performance as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175C8","prefix":"GG0175C8","text":"Once the patient is seated in the wheelchair, they should have the ability to wheel at least 150 feet in a corridor or similar space. The choices for this ability are with a manual wheelchair or indicating the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185F8","prefix":"GG0185F8","text":"The form asks about the patient's ability to answer a telephone call in their customary manner and maintain it for 1 minute or longer. This does not include getting to the phone. The label for the most dependent performance is used.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185K7","prefix":"GG0185K7","text":"The patient's usual performance in simple financial management includes the ability to complete financial transactions such as counting coins, verifying change for a single item transaction, writing a check, online/mobile bill pay, banking, or shopping.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175E7","prefix":"GG0175E7","text":"The form is asking about the patient's ability to wheel across a street using a manual wheelchair before the light turns red. The patient usually performs this task with their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130F8","prefix":"GG0130F8","text":"The form asks about the patient's ability to dress and undress above the waist, including dealing with fasteners if applicable, and the patient's most dependent performance is being evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175H7","prefix":"GG0175H7","text":"Once the patient is seated in the wheelchair or scooter, does he or she have the ability to wheel at least 150 feet in a corridor or similar space? The options are: Motorized Wheelchair/Scooter or Usual Performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170C7","prefix":"GG0170C7","text":"The form asks about the patient's usual performance in the ability to move from lying on their back to sitting on the side of the bed with their feet flat on the floor, and without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130G8","prefix":"GG0130G8","text":"The form asks about the patient's ability to dress and undress below the waist, including handling fasteners, but not including footwear. It indicates that the patient's performance in this area is mostly dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130D8","prefix":"GG0130D8","text":"The form asks about the patient's ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed. The performance level indicated is \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170K8","prefix":"GG0170K8","text":"The form asks if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The performance level is gauged as 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185E8","prefix":"GG0185E8","text":"The patient's performance level in light shopping is at its most dependent. Once at the store, they can locate and select up to five needed goods, take them to the checkout, and complete the purchasing transaction.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170W7","prefix":"GG0170W7","text":"Does the patient have the ability to walk for 15 minutes without stopping or resting, such as through a department store or supermarket, as part of their usual performance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170V7","prefix":"GG0170V7","text":"The form asks whether the patient has the ability to carry something in both hands, such as several dishes, a light laundry basket, or a tray with food, while walking indoors. The category for this question is 'Usual Performance.'","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170D8","prefix":"GG0170D8","text":"The form asks about the patient's ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. The patient's performance is most dependent in this regard.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920A2","prefix":"F0920A2","text":"Does the patient require unpaid assistance with self-care tasks such as bathing, dressing, toileting, or eating/feeding?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185G7","prefix":"GG0185G7","text":"The question on the form asks about the patient's or resident's usual performance in terms of the ability to place a call in their customary manner and maintain it for 1 minute or longer. Note that this does not include the act of getting to the phone.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185J7","prefix":"GG0185J7","text":"The patient's usual performance in medication management of injectable medications assesses their ability to prepare and take all prescribed injectable medications reliably and safely. This includes the administration of the correct dosage at the appropriate times or intervals.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170C8","prefix":"GG0170C8","text":"The form is asking about the patient's ability to move from lying on their back to sitting on the side of the bed with their feet flat on the floor, without any back support. The patient's performance in this task is categorized as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175J7","prefix":"GG0175J7","text":"The form asks the patient about their ability to wheel across a street before the light turns red once they are seated in a wheelchair or scooter. The options for response are 'Motorized Wheelchair/Scooter' and 'Usual Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185D7","prefix":"GG0185D7","text":"The patient's usual performance in the ability to complete heavier periodic housework, such as doing laundry, vacuuming, and cleaning the bathroom, is evaluated to ensure they can maintain a safe home environment and not be at risk for harm within their home.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185A8","prefix":"GG0185A8","text":"The form inquires about the patient's ability to plan and prepare all aspects of a light cold meal, such as a bowl of cereal, sandwich and cold drink. The patient's performance in this area is marked as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175G7","prefix":"GG0175G7","text":"Once the patient is seated in a wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. The options are either using a motorized wheelchair/scooter or executing their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170O7","prefix":"GG0170O7","text":"The patient's usual performance is their ability to go up and down 12 steps with or without a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175D8","prefix":"GG0175D8","text":"The patient's ability to wheel for 15 minutes once seated in a manual wheelchair, without stopping or resting, for example, through a department store or supermarket, is evaluated as the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185H8","prefix":"GG0185H8","text":"The form is asking about the patient's ability to manage their oral medications. This involves the preparation and safely taking all prescribed oral medications, including the administration of the correct dosage at the appropriate times/intervals. The level of performance is marked as \"most dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125F","prefix":"GG0125F","text":"Does the patient use an assistive device such as a mechanical lift?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175D7","prefix":"GG0175D7","text":"The form asks if the patient has the ability to wheel without stopping or resting for 15 minutes once seated in a manual wheelchair, such as when navigating through a department store or supermarket. The question is about their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170G8","prefix":"GG0170G8","text":"The form asks about the patient's ability to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten the seat belt. The patient's performance in this area is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170I8","prefix":"GG0170I8","text":"The form asks about the patient's ability to walk at least 10 feet once they are standing, whether it be in a room, corridor, or a similar space. The patient's performance is rated as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0180B","prefix":"GG0180B","text":"Please ask the patient to describe at least one or two personal priorities in the area of mobility for the next six months. If the patient does not express any personal priorities in this area, please note this below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0130A7","prefix":"GG0130A7","text":"The form is asking about the patient's usual performance in eating. It refers to their ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185G8","prefix":"GG0185G8","text":"The form asks about the patient's or resident's ability to place a call in their customary manner and maintain it for 1 minute or longer. It does not include getting to the phone. The patient's performance in this area is classified as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175E8","prefix":"GG0175E8","text":"The form asks about the patient's ability to wheel across a street once seated in a wheelchair before the light turns red. The options are from most dependent to a manual wheelchair performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185B7","prefix":"GG0185B7","text":"The form asks whether the patient has the ability to plan and prepare all aspects of a light hot meal, such as heating a bowl of soup and reheating a prepared meal. The label for this question is referring to the patient's usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125L","prefix":"GG0125L","text":"Does the patient use an assistive device such as grab bars?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0905B","prefix":"F0905B","text":"Please ask the patient to describe at least one or two personal priorities in the area of living arrangements for the next six months. If the patient does not express any personal priorities in this area, kindly note this down.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170U7","prefix":"GG0170U7","text":"The form asks about the patient's usual performance in their ability to walk indoors, specifically from room to room, and around furniture and other obstacles.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185E7","prefix":"GG0185E7","text":"The form asks about the patient's usual performance in light shopping tasks. Specifically, it asks if the patient can once at the store locate and select up to five needed goods, take them to the checkout, and complete the purchasing transaction.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170P8","prefix":"GG0170P8","text":"The form inquires about the patient's ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor. The performance level selected for the patient is \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185B8","prefix":"GG0185B8","text":"The form asks about the patient's ability to plan and prepare all aspects of a light hot meal, such as heating a bowl of soup and reheating a prepared meal. It is noted that the patient's performance in this area is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125Q","prefix":"GG0125Q","text":"Does the patient use an assistive device such as a hearing aid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125ZZ","prefix":"GG0125ZZ","text":"The patient has indicated all the assistive devices they needed.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-37/GG0170N8","prefix":"GG0170N8","text":"The form inquires about the patient's ability to go up and down four steps, with or without the assistance of a rail. The performance level was noted as \"most dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0900A2","prefix":"F0900A2","text":"Please identify the patient's or resident's usual living arrangement during the past month.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident} lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30925-4","display":"Person lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident} lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30926-2","display":"Person lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident} lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30927-0","display":"Person lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident} does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30928-8","display":"Person does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident} was in a medical facility."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30929-6","display":"Person was in a medical facility."}}]},{"linkId":"Section-37/GG0170J8","prefix":"GG0170J8","text":"Once the patient is standing, they will be assessed on their ability to walk at least 50 feet and make two turns. The potential ratings for performance in this task range from 'Most Dependent' to 'Independent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130EE7","prefix":"GG0130EE7","text":"The form inquires about the patient's usual performance regarding the ability to shower or bathe themselves, including tasks such as washing, rinsing, and drying themselves. It should be noted that this does not include the act of transferring in or out of the tub or shower.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185C7","prefix":"GG0185C7","text":"The form is asking about the patient's usual performance in terms of their ability to complete light daily housework. This entails maintaining a safe home environment so that the patient is not at risk from harm within their home. Examples of such housework include tasks like wiping counter tops or doing dishes.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130EE8","prefix":"GG0130EE8","text":"The form is asking about the patient's level of ability to bathe themselves, including washing, rinsing, and drying. The question does not include the process of transferring in and out of a tub or shower. The performance level designated is \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920A1","prefix":"F0920A1","text":"Does the patient require paid assistance for self-care activities such as bathing, dressing, toileting, or eating/feeding?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170E8","prefix":"GG0170E8","text":"The form asks about the patient's ability to transfer from a bed to a chair or wheelchair. It is labeled \"Most Dependent Performance\", indicating the need for assistance with this task.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125M","prefix":"GG0125M","text":"Does the patient use an assistive device such as a transfer board?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0130B8","prefix":"GG0130B8","text":"The form asks about the patient's ability to maintain oral hygiene by using suitable items to clean their teeth and, if applicable, their ability to insert and remove dentures into and from their mouth, as well as manage denture soaking and rinsing with the use of equipment. The response category for their performance is \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125S","prefix":"GG0125S","text":"The patient uses an assistive device, specifically stair rails.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0135B","prefix":"GG0135B","text":"Please ask the patient to describe at least one or two personal priorities in the area of self-care for the next six months. If the patient does not express any personal priorities in this area, please record this information below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170P7","prefix":"GG0170P7","text":"The form asks about the patient's usual performance in the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175C7","prefix":"GG0175C7","text":"Once the patient is seated in their manual wheelchair, their usual performance indicates their ability to wheel at least 150 feet in a corridor or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920E2","prefix":"F0920E2","text":"The patient has undergone medical procedures/treatments such as changing a wound dressing or a home exercise program, for which they have not paid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185K8","prefix":"GG0185K8","text":"The form asks about the patient's simple financial management skills, such as their ability to complete financial transactions, counting coins, verifying change for a single item transaction, writing a check, using online/mobile bill pay, banking, or shopping. The patient's performance is most dependent in these areas.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125C","prefix":"GG0125C","text":"Does the patient use an assistive device such as a wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185H7","prefix":"GG0185H7","text":"The patient's usual performance in medication management, specifically for oral medications, refers to their ability to prepare and take all prescribed oral medications reliably and safely. This includes administering the correct dosage at the appropriate times or intervals.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125P","prefix":"GG0125P","text":"Does the patient use an assistive device such as glasses or contact lenses?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175I7","prefix":"GG0175I7","text":"The form asks about the patient's ability to wheel for 15 minutes without stopping or resting, such as through a department store or supermarket, while seated in a wheelchair or scooter. Does the patient typically use a motorized wheelchair or scooter for this task?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125W","prefix":"GG0125W","text":"Does the patient use an assistive device such as a glucometer?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125T","prefix":"GG0125T","text":"Does the patient use an assistive device such as a lift chair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125D","prefix":"GG0125D","text":"Does the patient use an assistive device such as a limb prosthesis?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185J8","prefix":"GG0185J8","text":"The form asks about the patient's ability to manage injectable medications. It specifically addresses whether the patient can reliably and safely prepare and take all prescribed injectable medications, including the administration of the correct dosage at the correct times/intervals. The patient's performance in this area is marked as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125V","prefix":"GG0125V","text":"Does the patient use an assistive device such as a raised toilet seat?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Y","prefix":"GG0125Y","text":"Does the patient use an assistive device such as an oxygen concentrator?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175J8","prefix":"GG0175J8","text":"The question on the form is asking about the patient's ability, once seated in a wheelchair or scooter, to wheel across a street before the traffic light turns red. The answer choices are 'Motorized Wheelchair/Scooter' and 'Most Dependent Performance.'","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185I7","prefix":"GG0185I7","text":"The form asks about the patient's ability to manage their medication, specifically regarding inhalant or mist medications. It wants to know if the patient can prepare and take all prescribed inhalant or mist medications reliably and safely, including the correct dosage at the appropriate times or intervals. It asks for information about their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125U","prefix":"GG0125U","text":"Does the patient use an assistive device such as ramps?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0180A","prefix":"GG0180A","text":"Please ask the patient to describe at least one or two personal priorities in the area of mobility for the next six months. If the patient does not express any personal priorities in this area, please note this below. The answer options would be: A) Improvement in walking, B) Ability to climb stairs, C) Independence in moving, or D) No personal priorities.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0135A","prefix":"GG0135A","text":"Please ask the patient to describe at least one or two personal priorities in the area of self-care for the next six months. If the patient does not express any personal priorities in this area, please note this in their record.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0125K","prefix":"GG0125K","text":"Does the patient use an assistive device such as an electronic bed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125H","prefix":"GG0125H","text":"Does the patient use an assistive device such as a sock aid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920C2","prefix":"F0920C2","text":"The patient requires assistance with Instrumental Activities of Daily Living (IADL), such as making meals, housekeeping, telephone, shopping, or finances, which is currently unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0130A8","prefix":"GG0130A8","text":"The question on the form assesses the patient's ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them. The performance options range from independent to most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125J","prefix":"GG0125J","text":"Does the patient use an assistive device such as a bed rail?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920G1","prefix":"F0920G1","text":"Does the patient require supervision, for example due to safety concerns, and is this supervision paid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0125O","prefix":"GG0125O","text":"Does the patient use an assistive device such as a walk-in or wheel-in shower?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125B3","prefix":"GG0125B3","text":"Does the patient use an assistive device, specifically a walker with wheels?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125G","prefix":"GG0125G","text":"Does the patient use an assistive device such as a reacher or grabber?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170F7","prefix":"GG0170F7","text":"The form asks about the patient's usual performance in terms of their ability to get on and off a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125N","prefix":"GG0125N","text":"Does the patient require an assistive device such as a shower or commode chair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125X","prefix":"GG0125X","text":"Does the patient use an assistive device such as a Continuous Positive Airway Pressure (CPAP) machine?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125C1","prefix":"GG0125C1","text":"Does the patient use an assistive device such as a manual wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170G7","prefix":"GG0170G7","text":"The patient's usual performance indicates their ability to transfer in and out of a car or van on the passenger side. This does not include their ability to open/close the door or fasten the seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125B2","prefix":"GG0125B2","text":"Does the patient use an assistive device such as a walker with a seat?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185I8","prefix":"GG0185I8","text":"The form asks about the patient's ability to manage medication, specifically inhalant or mist medications. It wants to know if the patient can reliably and safely prepare and take all prescribed inhalant/mist medications, including the administration of the correct dosage at the appropriate times and intervals. The answer choices include 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130B7","prefix":"GG0130B7","text":"The form asks about the patient's oral hygiene, specifically their ability to use suitable items to clean their teeth. It also inquires about their use of dentures, if applicable, including their ability to insert and remove the dentures from their mouth, and manage denture soaking and rinsing with the use of equipment. The section is labeled \"Usual Performance.\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125I","prefix":"GG0125I","text":"Does the patient use an assistive device such as orthotics or a brace?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Z_specify","prefix":"GG0125Z_specify","text":"Does the patient use any other type of assistive device? If so, please specify.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170A8","prefix":"GG0170A8","text":"The patient's ability to roll from lying on their back to their left and right side, and return to lying on their back is most dependent on performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130CC7","prefix":"GG0130CC7","text":"The form asks about the patient's usual performance in maintaining toileting hygiene, specifically their ability to maintain perineal/menstrual hygiene and adjust clothing before and after voiding or having a bowel movement. If the patient manages an ostomy, it also includes wiping the opening but does not include managing equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920D1","prefix":"F0920D1","text":"The form asks about the patient's method of medication administration, with options that include oral, inhaled, or injectable medications. The medication administration for the patient is paid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0125E","prefix":"GG0125E","text":"Does the patient use an assistive device, such as a specialized seating pad (for example, an air-filled, gel, or shaped form pad)?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125C2","prefix":"GG0125C2","text":"Does the patient use an assistive device such as a motorized wheelchair and/or scooter?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170L8","prefix":"GG0170L8","text":"The form asks whether the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoors or outdoors. The answer choices for the patient's performance are: Most Independent Performance, Modified Independent, Supervision or Setup, Minimal Assistance, Moderate Assistance, Maximal Assistance, and Most Dependent Performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130CC8","prefix":"GG0130CC8","text":"The form asks the patient about their toileting hygiene, specifically their ability to maintain perineal/menstrual hygiene and adjust their clothes before and after voiding or having a bowel movement. If they are managing an ostomy, they should include their ability to wipe the opening, although managing the equipment is not necessary. The performance rating is either \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185A7","prefix":"GG0185A7","text":"The patient's usual performance demonstrates the ability to plan and prepare all aspects of a light, cold meal such as a bowl of cereal, sandwich, and cold drink.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920G2","prefix":"F0920G2","text":"The form asks if the patient requires supervision due to safety concerns, and specifies if this supervision is unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920C1","prefix":"F0920C1","text":"Does the patient require paid assistance for Instrumental Activities of Daily Living (IADL), such as making meals, housekeeping, using the telephone, shopping, or managing finances?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185L7","prefix":"GG0185L7","text":"The patient's usual performance in complex financial management involves the ability to complete financial decision-making tasks such as budgeting and remembering to pay bills.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185C8","prefix":"GG0185C8","text":"The form inquires about the patient's ability to perform light daily housework in order to maintain a safe home environment such that they are not at risk from harm within their own home. Examples of this housework might include tasks like wiping countertops or doing dishes. The patient's performance is labeled as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125R","prefix":"GG0125R","text":"Does the patient use an assistive device such as a communication device?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920F2","prefix":"F0920F2","text":"Does the patient manage their own equipment, such as oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies, without any payment?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185D8","prefix":"GG0185D8","text":"The form asks about the patient's ability to complete heavier periodic housework, like doing laundry, vacuuming, and cleaning the bathroom, in order to maintain a safe home environment. It also ensures the patient is not at risk for harm within their home. The category marked is 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170B8","prefix":"GG0170B8","text":"The form for the patient includes a question labeled \"Sit to lying\". This refers to the patient's ability to move from sitting on the side of the bed to lying flat on the bed. The performance is categorized as \"Most Dependent\", meaning the patient requires substantial assistance in this task.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130D7","prefix":"GG0130D7","text":"Does the patient have the ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed? Please rate their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0190A","prefix":"GG0190A","text":"Please ask the patient to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the patient does not express any personal priorities in this area, please note this below. Answer: A","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0905A","prefix":"F0905A","text":"Please ask the patient to describe at least one or two personal priorities in the area of their living arrangements for the next six months. If the patient does not express any personal priorities in this area, please note this below. The options are - A.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0920B1","prefix":"F0920B1","text":"Does the patient require mobility assistance, such as assistance with bed mobility, transfers, ambulating, or wheeling? If yes, is this assistance paid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185L8","prefix":"GG0185L8","text":"The form indicates the patient's level of ability in complex financial management, such as completing financial decision-making tasks including budgeting and remembering to pay bills. The patient's performance is recorded as mostly dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130H8","prefix":"GG0130H8","text":"The form asks about the patient's ability to put on and take off socks, shoes, or other appropriate footwear that is necessary for safe mobility, which includes dealing with fasteners, if applicable. The patient's performance in this aspect has been rated as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175H8","prefix":"GG0175H8","text":"The form is asking about the patient's ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter. The answer choices include 'Motorized Wheelchair/Scooter' and 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170A7","prefix":"GG0170A7","text":"The form asks about the patient's usual performance when it comes to their ability to roll from lying on their back to their left and right side, and then return to lying on their back.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185F7","prefix":"GG0185F7","text":"The form asks about the patient's ability to answer a telephone call in their customary manner and maintain the call for one minute or longer. It does not include getting to the phone. The question refers to the patient's usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175I8","prefix":"GG0175I8","text":"The patient questionnaire asked, \"Once the patient is seated in a wheelchair or scooter, do they have the ability to wheel without stopping or resting for 15 minutes (for example, through a department store or supermarket)?\" The answer choices include \"Motorized Wheelchair/Scooter\" and \"Most Dependent Performance.\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0190B","prefix":"GG0190B","text":"Please ask the patient to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the patient does not express any personal priorities in this area, note it below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0925A","prefix":"F0925A","text":"Please ask the patient to describe at least one or two personal priorities for their caregiving arrangement in the next six months. If the patient does not express any personal priorities in this area, please note this below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0925B","prefix":"F0925B","text":"Please ask the patient or resident to describe at least one or two personal priorities in the area of caregiving for the next six months. If the patient or resident does not express any personal priorities in this area, please note this below. The options are:\n\nA. The patient expresses personal priorities in the area of caregiving.\nB. The patient does not express any personal priorities in the area of caregiving.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170V8","prefix":"GG0170V8","text":"The form for the patient asks about his or her ability to carry something in both hands while walking indoors, such as several dishes, a light laundry basket, or a tray with food. The patient's performance in this area is identified as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]}],"_id":"ExjtWZvEMYRYgJCzu"} {"responseType":"QuestionnaireResponse","id":"his-ha-2.00.0","questionnaire":"HIS-HA-2.00.0","title":"Hospice Item Set - Hospice Admission Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-04-27T18:38:55.449Z","item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"The form asks for the patient's Medicaid number. The patient should enter \"+\" if their Medicaid status is pending, or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-36/A0800","prefix":"A0800","text":"What is the patient's gender? The possible answers could be male, female, or prefer not to say.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record for the patient needs to be specified.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0250","prefix":"A0250","text":"The reason for the patient's assessment needs to be determined.","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"What is the patient's admission date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Where was the patient immediately preceding this admission? Was the patient admitted from another hospital, a nursing home, their residence, or another location?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0550","prefix":"A0550","text":"What is the patient's ZIP code?","type":"text","repeats":false,"readOnly":false,"maxLength":11},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"Does the patient have a National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"What is the patient's CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"The form asks for the patient's suffix.","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A1000","prefix":"A1000","text":"The patient should check all the applicable boxes for their race or ethnicity.","type":"text","repeats":true,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A1400","prefix":"A1400","text":"The patient needs to fill out the payer information and must check all the options that apply to them.","type":"text","repeats":true,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0205","prefix":"A0205","text":"What was the site of service at the patient's admission?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0245","prefix":"A0245","text":"The date when the initial nursing assessment was initiated for the patient.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the patient, resident, or responsible party asked about their preference regarding the use of cardiopulmonary resuscitation (CPR)? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"The date on which the patient or responsible party was first asked about their preference regarding the use of CPR.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the patient, or their responsible party, asked about their preferences regarding life-sustaining treatments other than CPR? Select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"What was the date when the patient or responsible party was first asked about their preferences regarding life-sustaining treatments other than CPR?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the patient or the responsible party asked about their preference regarding hospitalization? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"The date when the patient, resident, or responsible party was first asked about their preference regarding hospitalization is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the patient or their caregiver asked about any spiritual or existential concerns? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"The date on which the patient or caregiver was first asked about spiritual or existential concerns is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-9/I0010","prefix":"I0010","text":"What is the patient's principal diagnosis?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the patient or resident screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"The date of the patient's first screening for pain was:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The severity of the patient's or resident's pain was:","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"What type of standardized pain tool was used for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Is pain an active problem for the patient or resident?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment conducted on the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"When was the patient's comprehensive pain assessment conducted?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"A comprehensive pain assessment was included for the patient where they needed to check all applicable options.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the patient or resident screened for any symptoms of shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"The date of the patient's first screening for shortness of breath was:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate that the patient had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"The form asks if treatment for the patient's shortness of breath was initiated. Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"What is the date when the treatment for shortness of breath was initiated for the patient?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"What types of treatment for shortness of breath have been initiated for the patient? Please check all that apply.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"The date the patient had their opioid treatment initiated or continued is scheduled for:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid medication initiated or continued for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"The date on which the patient's PRN opioid was initiated or continued is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued for the patient? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"The date on which the patient's bowel regimen was initiated or continued is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"The patient must provide their signature and title, as well as complete section A, including the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"The patient is required to provide their signature, title, and date they completed section B.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"The patient needs to provide their signature, title, and date on the completed C section of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"The patient needs to provide their signature, title, and the date on which they completed Section D of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"The patient needs to provide their signature, title, and the sections completed, along with the date when section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"The patient must sign, provide their title, complete all sections of the form, and include the date that each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"The patient needs to provide their signature and title, fill out the necessary sections, and date the section when it's completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"The patient is required to provide their signature, title, and the date they completed Section H on the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"The patient needs to provide their signature, title, and the date they completed section I.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title, complete the sections, and include the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature and title, and complete the sections indicated on the form. The date the section was completed should also be included.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"The patient's form must include their signature and title, the sections filled out, as well as the date each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"The patient needs to provide their signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"The date on which the RN Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false}],"_id":"4DHWajXmC4XLQzqJq"} {"responseType":"QuestionnaireResponse","id":"his-hd-2.00.0","questionnaire":"HIS-HD-2.00.0","title":"Hospice Item Set - Hospice Discharge Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-04-27T18:40:14.338Z","item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"The patient is required to enter a \"+\" if their Medicaid Number is pending or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-36/A0800","prefix":"A0800","text":"The patient's gender is being asked, with the answer choices being male, female, or prefer not to say.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record pertaining to the patient needs to be identified.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0250","prefix":"A0250","text":"What is the reason for the patient's assessment?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"The admission date of the patient is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0270","prefix":"A0270","text":"What is the patient's discharge date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"What is the patient's National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"What is the patient's CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"What is the patient's suffix?","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A2115","prefix":"A2115","text":"What was the patient's reason for discharge?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final three days of their life?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Did a registered nurse visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"The registered nurse visited the patient one day prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"The patient was visited by a registered nurse two days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant one day prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Did the patient visit a physician, nurse practitioner, or physician assistant two days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"The medical social worker visited the patient on the day of their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"The medical social worker visited the patient one day prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"The medical social worker visited the patient two days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Did the patient receive a visit from a chaplain or spiritual counselor on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Did the patient receive a visit from a chaplain or spiritual counselor one day prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Did the patient receive a visit from a Chaplain or Spiritual Counselor two days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Did the Licensed Professional Nurse visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Did the licensed professional nurse visit the patient one day prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Did the Licensed Professional Nurse visit the patient two days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Did an aide visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Did the aide visit the patient one day prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Did the aide visit the patient two days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final seven days of their life? This question refers to the level of care given in the final seven days.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"The patient was visited by a registered nurse three days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"The registered nurse visited the patient four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"The registered nurse visited the patient five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"The registered nurse visited the patient six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Did the patient visit a physician, nurse practitioner, or physician assistant three days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Did the patient visit a physician, nurse practitioner, or physician assistant four days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"The patient was visited by a physician, nurse practitioner, or physician assistant five days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Did the patient visit a physician, nurse practitioner, or physician assistant six days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Did the medical social worker visit the patient three days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"The medical social worker visited the patient four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"The medical social worker visited the patient five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"The medical social worker visited the patient six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Did the patient have a visit from a chaplain or spiritual counselor three days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"The patient's chaplain or spiritual counselor visited four days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"The patient was visited by a Chaplain or Spiritual Counselor five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Did the patient receive a visit from a chaplain or spiritual counselor six days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"The patient was visited by a Licensed Professional Nurse three days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"The patient was visited by a Licensed Professional Nurse four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Did the licensed professional nurse visit the patient five days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"The patient was visited by a Licensed Professional Nurse six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Did the aide visit the patient three days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"The patient received visits from the aide four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Did the aide visit the patient five days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Did the aide visit the patient six days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"The patient is required to provide their signature and title, and to acknowledge the sections and date that the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"The patient is required to provide their signature, title, and the date on which they completed Section B.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"The patient is asked to provide their signature and title in the designated sections, and to also indicate the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"The form for the patient asks for the patient's signature, their title, the sections they have completed, and the date they completed section D.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"The section indicated as \"Signature, Title, Sections, Date Section Completed E\" on the patient's form needs to be filled out.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"The patient's signature, title, and the date of completion are required in section F.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"The patient is required to provide their signature and title in the designated sections and indicate the date when they completed Section G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"The patient's form includes sections for signature, title, and date of completion, all of which must be filled out by Section H.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"The patient must provide their signature, title, date, and completed sections in section I.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title, and complete sections J of the form. This needs to be done by a specific date.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"The sections, signature, title, and the date when the section was completed are required information for patient K's form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"The sections of the form, including the signature, title, and date section, were completed by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"The form requires the patient's signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"The date on which the RN Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false}],"_id":"3KbkKW9X6KL7S92sv"} {"responseType":"QuestionnaireResponse","id":"irf-pai-ia-3.0","questionnaire":"IRF-PAI-IA-3.0","title":"Inpatient Rehabilitation Facility Patient Assessment Instrument - IRF Admission","description":"Assessment data collected on all Medicare Part A fee-for-service patients who receive services under Part A from an inpatient rehabilitation facility (IRF) at admission and upon discharge.","status":"draft","authored":"2024-04-27T18:34:15.837Z","item":[{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0700","prefix":"A0700","text":"The patient should enter a \"+\" in the Medicaid Number field if the application is pending, or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-38/A0800","prefix":"A0800","text":"The patient's gender is required. Is the patient male or female?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Male"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Female"}}]},{"linkId":"Section-38/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/A1200","prefix":"A1200","text":"What is the patient's marital status? Is he/she single, married, divorced, separated, or widowed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Never married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Widowed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Separated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Divorced"}}]},{"linkId":"Section-38/A0220","prefix":"A0220","text":"What is the admission date for the patient?","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/11","prefix":"11","text":"What is the zip code of the patient's or resident's pre-hospital residence?","type":"text","repeats":false,"readOnly":false,"maxLength":5},{"linkId":"Section-38/13","prefix":"13","text":"The assessment reference date for the patient has been set.","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/14","prefix":"14","text":"The admission class of the patient is categorized under which category?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Initial Rehab"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Evaluation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Readmission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unplanned Discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Continuing Rehabilitation"}}]},{"linkId":"Section-38/17","prefix":"17","text":"Does the patient live at home prior to hospitalization? If the pre-hospital living setting is the patient's home, please code accordingly.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Alone"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Family / Relatives"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Friends"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Attendant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Other"}}]},{"linkId":"Section-38/15A","prefix":"15A","text":"From where was the patient admitted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}}]},{"linkId":"Section-38/16A","prefix":"16A","text":"The patient's pre-hospital living setting is required. Please use codes from the 'Admit From' category.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}}]},{"linkId":"Section-38/1A","prefix":"1A","text":"What is the name of the facility or provider for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":50},{"linkId":"Section-38/5B","prefix":"5B","text":"What is the patient's or resident's identification number?","type":"text","repeats":false,"readOnly":false,"maxLength":50},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Please check all the boxes that apply to the patient's race and ethnicity.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}]},{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Please record the most recent height measurement in inches for the patient since their admission.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"The patient's weight in pounds should be based on the most recent measure taken within the specified time period. The weight measurement must be executed consistently, adhering to the standard practice of the facility or setting, such as in the morning after voiding, before meals, with shoes off, etc.","type":"integer","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-41/21A","prefix":"21A","text":"The impairment group upon admission refers to the condition that required the patient to be admitted to rehabilitation; this should be coded according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-41/23","prefix":"23","text":"When did the impairment of the patient first begin?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Does the patient have any arthritis conditions recorded in either the impairment group, etiologic diagnosis, or comorbid conditions that meet all the regulatory requirements for Inpatient Rehabilitation Facility (IRF) classification?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-41/22A","prefix":"22A","text":"The form asks for the patient's etiologic diagnosis A.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/22B","prefix":"22B","text":"The form asks the patient for their etiologic diagnosis B.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/22C","prefix":"22C","text":"The form for the patient includes a section on etiologic diagnosis C.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24A","prefix":"24A","text":"Does the patient have Comorbid Condition A?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24B","prefix":"24B","text":"Does the patient have Comorbid Condition B?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24C","prefix":"24C","text":"Does the patient have Comorbid Condition C?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24D","prefix":"24D","text":"Does the patient have a comorbid condition D?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24E","prefix":"24E","text":"Does the patient have a comorbid condition E?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24F","prefix":"24F","text":"Does the patient have a comorbid condition F?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24G","prefix":"24G","text":"Does the patient have a comorbid condition G?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24H","prefix":"24H","text":"Does the patient have a comorbid condition H? Please select 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24I","prefix":"24I","text":"Does the patient have a comorbid condition? Please select either 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24J","prefix":"24J","text":"Does the patient have comorbid condition J?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24K","prefix":"24K","text":"Does the patient have a comorbid condition K?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24L","prefix":"24L","text":"Does the patient have any comorbid conditions? Please list them.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24M","prefix":"24M","text":"The patient has a comorbid condition labelled as M.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24N","prefix":"24N","text":"Does the patient have any comorbid conditions? Please select 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24O","prefix":"24O","text":"Does the patient have any comorbid conditions?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24P","prefix":"24P","text":"Does the patient have a comorbid condition P?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Does the patient have a comorbid condition?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24R","prefix":"24R","text":"Does the patient have a comorbid condition R?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24S","prefix":"24S","text":"The form inquires about the patient's comorbid conditions.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24T","prefix":"24T","text":"Does the patient have a comorbid condition? Please choose one: Yes or No.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24U","prefix":"24U","text":"The patient has a comorbid condition, referred to as Condition U.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24V","prefix":"24V","text":"Does the patient have a comorbid condition V?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24W","prefix":"24W","text":"Does the patient have a comorbid condition W?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24X","prefix":"24X","text":"Does the patient have a comorbid condition X?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Does the patient have a comorbid condition labeled as Y?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-40/20A","prefix":"20A","text":"The primary source of information about the patient is the patient themselves.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}]},{"linkId":"Section-40/20B","prefix":"20B","text":"The form asks the patient to provide a secondary source of information.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}]},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"The patient's ability to express ideas and wants, considering both verbal and non-verbal expression and excluding language barriers, is being evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}]},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Does the patient understand verbal and non-verbal content with the use of a hearing aid or device, excluding language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}]},{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should a brief interview for mental status be conducted? An attempt should be made to conduct an interview with all patients or residents.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-3/C0200","prefix":"C0200","text":"The form asks the patient: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" The form then records the number of words the patient repeated after the first attempt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}]},{"linkId":"Section-3/C0500","prefix":"C0500","text":"The BIMS Summary Score requires the addition of scores for the Brief Interview for Mental Status questions, with the total score filled in, ranging from 00-15. If the patient or resident was unable to complete the interview, enter 99.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the staff conduct an assessment for the patient's mental status?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}]},{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"The form asks the patient, \"Please tell me what year it is right now,\" to determine if they are able to accurately report the current year.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}]},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"The form asks the patient: \"What month are we in right now?\" The patient is expected to be able to report the correct month.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}]},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"The form asks the patient, \"What day of the week is today?\" The patient is then expected to be able to report the correct day of the week.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}]},{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"The patient is able to recall the word \"sock\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"The patient is able to recall the color \"blue\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Is the patient able to recall the word \"bed\"?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0900","prefix":"C0900","text":"The form asked to check all the items that the patient or resident was normally able to recall, indicating their memory or recall ability.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}]},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"The question on the form asks about the patient's ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them. This refers to their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"The patient's oral hygiene refers to their ability to use suitable items to clean their teeth. If applicable, their ability to handle dentures is evaluated by their capability to insert and remove them into and from the mouth, as well as successfully managing the soaking and rinsing of the dentures with the use of equipment. This is part of their admission performance assessment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"Does the patient have the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement? If the patient is managing an ostomy, does this include wiping the opening but not managing the equipment? Please assess their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"The discharge goal for the patient or resident is to gain the ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"The patient's oral hygiene pertains to their ability to use suitable items to clean their teeth. If applicable, their denture care involves the ability to insert and remove dentures into and from the mouth, as well as managing denture soaking and rinsing with the use of equipment. The discharge goal is to ensure these abilities.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"The discharge goal is for the patient to have the ability to maintain perineal hygiene, adjust their clothes before and after voiding or having a bowel movement. If they are managing an ostomy, this includes wiping the opening but not managing the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"The form asks about the patient's ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed during their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"The form asks about the patient's ability to move from sitting on the side of the bed to lying flat on the bed at the time of admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"The form asks about the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. This is referred to as 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"The discharge goal for the patient is to have the ability to roll from lying on their back to their left and right side, and then return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"The discharge goal for the patient includes the ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"The patient's discharge goal is the ability to move from lying on the back to sitting on the side of the bed without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"Does the patient have the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"The patient's admission performance includes the ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"The admission form poses a question regarding the patient's ability to transfer to and from a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"The question on the form asks about the patient's admission performance, specifically their ability to walk at least 10 feet in a room, corridor, or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"The form asks about the patient's admission performance, specifically their ability to walk at least 50 feet and make two turns once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"The form asks about the patient's admission performance, specifically, once standing, does the patient have the ability to walk at least 150 feet in a corridor or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"Once the patient is seated in the wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. This is a requirement for admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"The form asks about the patient's admission performance regarding their ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K3","prefix":"GG0170K3","text":"Does the patient have the ability, once standing, to walk at least 150 feet in a corridor or similar space? This will be evaluated as part of their discharge performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"The discharge goal for the patient is to develop the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"The discharge goal for the patient is to be able to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"The discharge goal for the patient is to have the ability to get on and off a toilet or commode independently.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"The discharge goal for the patient is to achieve the ability to walk at least 10 feet once standing, whether it's in a room, corridor, or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"The form asks if, once standing, the patient has the ability to walk at least 50 feet and make two turns. The answer options for this question are \"Yes\" or \"No\". This information will help set a discharge goal for the patient.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"The form inquires if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The goal is to attain this ability by the time of discharge.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"The discharge goal for the patient is to be able once seated in the wheelchair or scooter, to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"The discharge goal for the patient is to have the ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the patient or resident use a wheelchair and/or scooter upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Please indicate the type of wheelchair or scooter that the patient uses upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"The patient is required to indicate the type of wheelchair or scooter used upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"The form inquires about the patient's ability to bathe themselves, which includes washing, rinsing, and drying themselves, excluding washing of the back and hair. It does not consider the ability to transfer in or out of the tub or shower. This information is required for the Admission Performance assessment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"The admission performance form inquires about the patient's ability to dress and undress above the waist, including the handling of fasteners if applicable, under the section labeled 'Upper Body Dressing'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"On the admission form, it asks about the patient's ability to dress and undress below the waist, including handling fasteners. It does not include dealing with footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"The form asks about the patient's ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable. This is in reference to their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"The form asks about the patient's ability to transfer in and out of a car or van from the passenger side upon admission. This does not include the patient's ability to open or close the door or fasten their seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"The form asks about the patient's ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel, in terms of their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"The form asks about the patient's ability to go up and down a curb and/or up and down one step, as a measure of their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170N1","prefix":"GG0170N1","text":"The patient's admission performance indicates their ability to go up and down four steps, either with or without the aid of a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170O1","prefix":"GG0170O1","text":"The question on the form asks about the patient's ability to go up and down 12 steps with or without a rail. The label is \"Admission Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170P1","prefix":"GG0170P1","text":"The form asks about the patient's ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor. This question is referred to as the 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130E2","prefix":"GG0130E2","text":"The form asks about the patient's ability to shower or bathe themselves, which includes washing, rinsing, and drying, but excludes washing of the back and hair. It is important to note, this does not include the patient's ability to transfer in and out of the tub or shower. The focus of this question is to understand the patient's discharge goal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130F2","prefix":"GG0130F2","text":"The patient's discharge goal includes developing the ability to dress and undress themselves above the waist, including managing fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130G2","prefix":"GG0130G2","text":"The discharge goal for the patient is to develop the ability to dress and undress below the waist, including handling fasteners, but this does not include managing footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130H2","prefix":"GG0130H2","text":"The discharge goal for the patient is to develop the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including managing fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"The patient's discharge goal is to be able to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten the seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"The patient's discharge goal is to have the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoors or outdoors.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"The discharge goal for the patient is the ability to go up and down a curb and/or up and down one step.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"The discharge goal for the patient is to develop the ability to go up and down four steps, with or without the assistance of a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"The discharge goal for the patient is to have the ability to go up and down 12 steps with or without a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"The discharge goal for the patient is to develop the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Please code the patient's or resident's need for assistance with activities such as bathing, dressing, using the toilet, and eating prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"The form asks for the patient's or resident's level of need for assistance with indoor mobility, specifically walking from room to room, prior to the current illness, exacerbation, or injury. This includes whether they required a device such as a cane, crutch, or walker.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Please code the patient's or resident's need for assistance with internal or external stairs, whether with or without a device such as a cane, crutch, or walker, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Please code the patient's need for assistance with planning regular tasks, such as shopping or remembering to take medication, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"The form asks for information about the devices and aids that the patient or resident was using prior to their current illness, exacerbation, or injury. It requests that all applicable options be checked.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Please select the category that best describes the bowel continence of the patient or resident.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}]},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Please select the one category that best describes the patient's bladder continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}]},{"linkId":"Section-9/I0000","prefix":"I0000","text":"The form asks the patient to check all active diagnoses they have had in the last 7 days. It should be noted that the diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-10/J1750","prefix":"J1750","text":"Does the patient or resident have a history of falls, specifically, have they experienced two or more falls in the past year or any fall that resulted in injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}]},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Did the patient have any major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}]},{"linkId":"Section-11/K0110","prefix":"K0110","text":"Indicate the patient's usual ability to swallow by checking all applicable boxes pertaining to their swallowing and nutritional status.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}]},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Does the patient or resident have one or more unhealed pressure ulcers or injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"The form is asking the patient to report the number of Stage 2 pressure ulcers they currently have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"The patient has been asked to indicate the number of Stage 3 pressure ulcers they have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"The patient has a certain number of stage 4 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"How many unstageable pressure ulcers or injuries does the patient have due to a non-removable dressing or device?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"The form is asking the patient about the number of unstageable pressure ulcers they have due to the coverage of the wound bed by slough and/or eschar.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"The patient has a number of unstageable pressure injuries presenting as deep tissue injury.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"The form is asking the patient to disclose the number of Stage 1 pressure injuries they have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Did a complete drug regimen review conducted for the patient identify any potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}]},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Did the facility or setting contact a physician or a designated representative by midnight of the next calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues for the patient?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-15/O0100","prefix":"O0100","text":"The patient should check all of the following special treatments, procedures, and programs that were performed on them.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}]},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"The form for the patient includes sections such as the signature, title, and date section A that need to be completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"The patient must provide their signature, title, and date in the sections where the section completion is indicated by a 'B'.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"The sections labeled \"Signature\", \"Title\", \"Sections\", and \"Date Section Completed C\" must be filled out by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"The sections of the form completed by the patient are signed and dated, with their title also mentioned.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"The patient should fill out the signature, title, and sections, then indicate the date the section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"The patient's signature, title, and the date the form sections were completed are required in section F.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"The patient needs to provide their Signature, Title, and complete the Sections mentioned in the form, including the Date Section Completed G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"The patient needs to include their signature, title, and date on the completed sections H of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"The patient needs to provide their signature and title, complete the sections, and indicate the date on which the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"The patient is required to provide their signature, title, and the date on which the sections were completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature, their title, and fill out the sections on the form, indicating the date each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"The patient's form includes a signature, title, sections, and a section indicating the date the form was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100}],"_id":"qgcQEoQz3XK7sPK8x"} {"id":"pbupcoBuWyD8N7qtY","responseType":"QuestionnaireResponse","status":"draft","authored":"2024-04-27T18:36:21.698Z","item":[{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0800","prefix":"A0800","text":"What is the patient's gender?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Female"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}]},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1100B","prefix":"A1100B","text":"What is the patient's preferred language?","type":"text","repeats":false,"readOnly":false,"maxLength":15},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"The form for the patient asks for their suffix.","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"What is the patient's National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-3/C1610E1","prefix":"C1610E1","text":"The patient's alertness level is normal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the patient or resident use a wheelchair and/or scooter upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"How many Stage 1 pressure injuries does the patient have?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"The patient has a certain number of stage 4 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0200","prefix":"A0200","text":"The type of provider for the patient needs to be specified.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Long-Term Care Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28448-1","display":"Long-term care hospital "}}]},{"linkId":"Section-15/O0250B","prefix":"O0250B","text":"What is the date the patient received the influenza vaccine?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0100C","prefix":"A0100C","text":"The patient's State Medicaid Facility or Provider Number is required.","type":"text","repeats":false,"readOnly":false,"maxLength":15},{"linkId":"Section-9/I0050","prefix":"I0050","text":"Please indicate the primary medical condition category for the patient or resident.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Acute Onset Respiratory Condition (e.g., aspiration and specified bacterial pneumonias)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27513-3","display":"Acute onset respiratory condition (e.g., aspiration and specified bacterial pneumonias)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Chronic Respiratory Condition (e.g., chronic obstructive pulmonary disease)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27514-1","display":"Chronic respiratory condition (e.g., chronic obstructive pulmonary disease)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Acute Onset and Chronic Respiratory Conditions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27515-8","display":"Acute onset and chronic respiratory conditions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Chronic Cardiac Condition (e.g., heart failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27516-6","display":"Chronic cardiac condition (e.g., heart failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Other Medical Condition. If \"Other Medical Condition\", enter ICD code in the boxes."}},{"valueCoding":{"system":"http://loinc.org","code":"LA16346-1","display":"Other medical condition"}}]},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"The patient has a certain number of Stage 2 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0210","prefix":"A0210","text":"The assessment reference date refers to the patient's observation end date.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1400","prefix":"A1400","text":"The patient needs to provide their payer information by checking all the boxes that apply.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Medicare (traditional fee-for-service)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6259-1","display":"Medicare (traditional fee-for-service)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Medicare (managed care/Part C/Medicare Advantage)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27554-7","display":"Medicare (managed care/Part C/Medicare Advantage)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Medicaid (traditional fee-for-service)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6257-5","display":"Medicaid (traditional fee-for-service)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Medicaid (managed care)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27556-2","display":"Medicaid (managed care)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Workers' compensation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6452-2","display":"Workers' compensation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Title programs (e.g., Title III, V, or XX)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6398-7","display":"Title programs (e.g., Title III, V, or XX)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Other government (e.g., TRICARE, VA, etc.)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10049-7","display":"Other government (e.g., TRICARE, VA, etc.)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Private insurance/Medigap"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10061-2","display":"Private insurance/Medigap"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Private managed care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27561-2","display":"Private managed care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Self-pay"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6369-8","display":"Self-pay"}},{"valueCoding":{"system":"http://del.cms.gov","code":"K","display":"No payer source"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18995-3","display":"No payor source"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"Other"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}]},{"linkId":"Section-15/O0100","prefix":"O0100","text":"Please check all of the following special treatments, procedures, and programs that were performed on the patient.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Non-invasive Ventilator (BIPAP, CPAP)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27542-2","display":"Non-invasive ventilator (BIPAP, CPAP)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"IV Medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27972-1","display":"IV medications, (if checked, please specify below)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H2a","display":"Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28269-1","display":"Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Dialysis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA7216-0","display":"Dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-36/A0250","prefix":"A0250","text":"What is the reason for the patient's assessment?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Admission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10922-5","display":"Admission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Planned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18067-1","display":"Planned discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"12","display":"Expired"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10325-1","display":"Expired"}}]},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record for the patient needs to be identified.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Add new assessment/record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27573-7","display":"Add new assessment/record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Modify existing record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12664-1","display":"Modify existing record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Inactivate existing record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12665-8","display":"Inactivate existing record"}}]},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"The sections were completed and dated by the patient, who then signed and titled the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"The patient has a certain number of unstageable pressure injuries that are presenting as deep tissue injury.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Where was the patient immediately preceding this admission? Was the patient admitted from home, another healthcare facility, or somewhere else?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11501-6","display":"Community residential setting (e.g., private home, assisted living, group home, adult foster care)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Long-term care facility (LTC)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18066-3","display":"Long-term care facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Hospital emergency department"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11504-0","display":"Hospital emergency department"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Short-stay acute hospital (IPPS)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10078-6","display":"Short-stay acute hospital (IPPS)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"Inpatient rehabilitation facility or unit (IRF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27548-9","display":"Inpatient rehabilitation facility or unit (IRF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"Psychiatric hospital or unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10065-3","display":"Psychiatric hospital or unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Intellectually Disabled/Developmentally Disabled (ID/DD) facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28224-6","display":"Intellectually disabled/developmentally disabled (ID/DD) facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Hospice"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6216-1","display":"Hospice"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-15/O0250A","prefix":"O0250A","text":"Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"The patient must provide their signature, title, and the date on which they completed Section I of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"The patient needs to provide their Signature, Title, and the Date they completed Section D.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-2/B0100","prefix":"B0100","text":"The patient is in a comatose state with no discernible consciousness, persisting in a vegetative state.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Please select the one category that best describes the patient's bladder continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}]},{"linkId":"Section-3/C1610A","prefix":"C1610A","text":"Is there evidence of an acute change in the patient's or resident's mental status from their baseline?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Did a complete drug regimen review for the patient identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}]},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Does the patient understand both verbal and non-verbal content with the use of their hearing aid or device, excluding any language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}]},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Does the patient express their ideas and wants, considering both verbal and non-verbal expression and excluding language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}]},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"The discharge goal for the patient is to have the ability to get on and off a toilet or commode independently.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"The form asks about the patient's admission performance regarding their ability to transfer to and from a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-36/A1200","prefix":"A1200","text":"What is the patient's marital status? Is the patient single, married, divorced, separated, or widowed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Divorced"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}]},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"The discharge goal for the patient is to have the ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0500B","prefix":"Z0500B","text":"The date on which the Registered Nurse Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-15/O0150B","prefix":"O0150B","text":"The patient was assessed for readiness for spontaneous breathing trial (SBT) by the second day of their Long Term Care Hospital (LTCH) stay.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Does this patient or resident have one or more unhealed pressure ulcers or injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"The signature, title, and date of the section completed F were filled out by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-36/A1100A","prefix":"A1100A","text":"Does the patient need or want an interpreter to communicate with a doctor or health care staff? Please indicate 'yes' or 'no'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Unable to determine"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11137-9","display":"Unable to determine"}}]},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"The patient completed section B and then they signed and dated the form, also providing their title.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-15/O0150A","prefix":"O0150A","text":"Was the patient on invasive mechanical ventilator support upon admission to the Long-Term Care Hospital?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No, not on invasive mechanical ventilation support upon admission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28329-3","display":"No, not on invasive mechanical ventilation support"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, weaning"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28330-1","display":"Yes, weaning"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, non-weaning"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28331-9","display":"Yes, non-weaning"}}]},{"linkId":"Section-9/I0050A","prefix":"I0050A","text":"If the patient has an \"Other Medical Condition\", they should enter the ICD code in the provided boxes.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"How many unstageable pressure ulcers does the patient have due to the coverage of the wound bed by slough and/or eschar?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"The patient's signature, title, and the date are required in the completed Section G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"The form requires the patient's signature, title, the sections they completed, and the date on which Section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-11/K0200A","prefix":"K0200A","text":"Please record the most recent measurement of the patient's height in inches since their admission.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"The admission date of the patient is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-19/Z0500A","prefix":"Z0500A","text":"The form requires the patient's signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Please select the one category that best describes the patient's or resident's bowel continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}]},{"linkId":"Section-36/A1000","prefix":"A1000","text":"The patient should check all the applicable options for their race or ethnicity.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}]},{"linkId":"Section-3/C1610B","prefix":"C1610B","text":"Did the patient's abnormal behavior fluctuate during the day, that is, did it tend to come and go or increase and decrease in severity?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title in the designated sections and also indicate the date when each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"The form asks if, once standing, the patient has the ability to walk at least 50 feet and make two turns for their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"How many Stage 3 pressure ulcers does the patient have?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"The form asks about the patient's admission performance regarding their ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"The form asks about the patient's admission performance in regards to their ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"The discharge goal for the patient is to gain the ability to stand up and walk at least 10 feet in a room, corridor, or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"The form asks about the patient's admission performance in terms of their ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-3/C1610E2","prefix":"C1610E2","text":"Is the patient vigilant (hyperalert), lethargic (drowsy, easily aroused), in a stupor (difficult to arouse), or in a coma (unarousable)?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature and title, and complete the relevant sections. The date when the section was completed is also required.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"The discharge goal for the patient is to achieve the ability to walk at least 150 feet in a corridor or similar space, once they are able to stand.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"The patient must provide their signature and title, as well as complete the sections indicated. The date when the section was completed has to be marked as 'A'.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0130D1","prefix":"GG0130D1","text":"The admission performance form inquires about the patient's ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"The form asks about the patient's admission performance, specifically inquiring about their ability to stand and walk at least 150 feet in a corridor or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"The discharge goal for the patient or resident is to gain the ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"The discharge goal for the patient is to once be seated in a wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"The form asks about the patient's admission performance, specifically whether, once seated in a wheelchair or scooter, they are able to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"The section labeled \"Signature, Title, Sections, Date Section Completed L\" on the patient's form needs to be filled out.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"How many unstageable pressure ulcers or injuries does the patient have due to a non-removable dressing or device?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-15/O0150C","prefix":"O0150C","text":"The patient was deemed medically ready for Spontaneous Breathing Trial (SBT) by day 2 of their Long Term Care Hospital (LTCH) stay.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"The form asks about the patient's admission performance in relation to their ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-9/I0000","prefix":"I0000","text":"Has the patient had any active diagnoses in the last 7 days? Please check all that apply. The diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0103","display":"Metastatic Cancer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28289-9","display":"Metastatic cancer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0104","display":"Severe Cancer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28290-7","display":"Severe cancer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0605","display":"Severe Left Systolic/Ventricular Dysfunction (known ejection fraction <= 30%)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28298-0","display":"Severe left systolic/ventricular dysfunction (known ejection fraction <= 30%)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1501","display":"Chronic Kidney Disease, Stage 5"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27518-2","display":"Chronic kidney disease, stage 5"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1502","display":"Acute Renal Failure"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27519-0","display":"Acute renal failure"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2101","display":"Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27520-8","display":"Septicemia, sepsis, systemic inflammatory response syndrome/shock"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2600","display":"Central Nervous System Infections, Opportunistic Infections, Bone/Joint/Muscle Infections/Necrosis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27521-6","display":"Central nervous system infections, opportunistic infections, bone/joint/muscle infections/necrosis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27539-8","display":"Diabetes mellitus (DM)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4100","display":"Major Lower Limb Amputation (e.g., above knee, below knee)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27522-4","display":"Major lower limb amputation (e.g., above knee, below knee)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4501","display":"Stroke"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22099-8","display":"Stroke"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4801","display":"Dementia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA20372-1","display":"Dementia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4900","display":"Hemiplegia or Hemiparesis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27523-2","display":"Hemiplegia or hemiparesis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5000","display":"Paraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA25276-9","display":"Paraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5101","display":"Complete Tetraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27528-1","display":"Complete tetraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5102","display":"Incomplete Tetraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27529-9","display":"Incomplete tetraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5110","display":"Other Spinal Cord Disorder/Injury (e.g., myelitis, cauda equina syndrome)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27530-7","display":"Other spinal cord disorder/injury (e.g., myelitis, cauda equina syndrome)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5200","display":"Multiple Sclerosis (MS)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27531-5","display":"Multiple sclerosis (MS)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5250","display":"Huntington's Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27532-3","display":"Huntington's disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5300","display":"Parkinson's Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27533-1","display":"Parkinson's disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5450","display":"Amyotrophic Lateral Sclerosis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27534-9","display":"Amyotrophic lateral sclerosis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5455","display":"Other Progressive Neuromuscular Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28291-5","display":"Other progressive neuromuscular disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5460","display":"Locked-In State"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27535-6","display":"Locked-in state"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5470","display":"Severe Anoxic Brain Damage, Cerebral Edema, or Compression of Brain"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27536-4","display":"Severe anoxic brain damage, cerebral edema, or compression of brain"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5480","display":"Other Severe Neurological Injury, Disease, or Dysfunction"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28292-3","display":"Other severe neurological injury, disease, or dysfunction"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5601","display":"Malnutrition (protein or calorie)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27537-2","display":"Malnutrition (protein or calorie)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5602","display":"At Risk for Malnutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27538-0","display":"At risk for malnutrition"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7100","display":"Lung Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28293-1","display":"Lung transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7101","display":"Heart Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28294-9","display":"Heart transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7102","display":"Liver Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28295-6","display":"Liver transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7103","display":"Kidney Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28296-4","display":"Kidney transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7104","display":"Bone Marrow Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28297-2","display":"Bone marrow transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-36/A0700","prefix":"A0700","text":"The patient should enter a \"+\" in the Medicaid Number section if their Medicaid application is pending, or \"N\" if they are not a recipient of Medicaid.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"The discharge goal for the patient pertains to their ability to transfer to and from a bed to a chair, which could also include a wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"The discharge goal for the patient is the ability to transition from lying on their back to sitting on the side of the bed without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Please code the patient's or resident's need for assistance with walking from room to room, with or without a device such as a cane, crutch, or walker, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - a helper completed the activity for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-3/C1610D","prefix":"C1610D","text":"Was the patient's or resident's thinking disorganized or incoherent, characterized by rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switches from subject to subject?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"The discharge goal for the patient is to attain the ability to stand and walk at least 50 feet, making two turns once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"The sections of the form, including the signature and title sections, were completed by the patient on the date indicated in the \"Date Section Completed H\".","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Does the patient have the ability to walk at least 10 feet in a room, corridor, or similar space once they are standing? Select from the following options for their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Did the facility or setting contact a physician, or the physician's designee, by midnight of the next calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"The discharge goal for the patient pertains to their ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, which is referred to as \"sit to stand\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"The discharge goal for the patient includes their ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If they are managing an ostomy, this will also include wiping the opening, but not managing the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"The form is questioning the patient's ability, once seated in a wheelchair or scooter, to wheel at least 150 feet in a corridor or similar space. This is a discharge goal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-3/C1610C","prefix":"C1610C","text":"Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? The possible answers could be 'Yes', 'No', or 'Sometimes'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-15/O0150D","prefix":"O0150D","text":"Is there documentation of the reason or reasons in the patient's or resident's medical record that indicates why the patient or resident was deemed medically unready for SBT by the second day of their stay at the Long-Term Care Hospital?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0130D2","prefix":"GG0130D2","text":"The discharge goal for the patient is to have the ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-15/O0250C","prefix":"O0250C","text":"If the patient has not received the influenza vaccine, please state the reason. The options may include: a) allergic to the vaccine, b) vaccine not available, c) personal beliefs, or d) other reasons.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"{Patient/resident} not in facility during this year's influenza vaccination season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26745-2","display":"Patient not in this facility during this year's influenza vaccination season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Received outside of this facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA184-4","display":"Received outside of this facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Not eligible - medical contraindication"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11091-8","display":"Not eligible - medical contraindication"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Offered and declined"}},{"valueCoding":{"system":"http://loinc.org","code":"LA186-9","display":"Offered and declined"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Not offered"}},{"valueCoding":{"system":"http://loinc.org","code":"LA187-7","display":"Not offered"}},{"valueCoding":{"system":"http://del.cms.gov","code":"6","display":"Inability to obtain influenza vaccine due to a declared shortage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26746-0","display":"Inability to obtain influenza vaccine due to a declared shortage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"The question on the form refers to the patient or resident's eating abilities, specifically their ability to utilize appropriate utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is presented to them. This is evaluated based on their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-15/O0150E","prefix":"O0150E","text":"If the patient or resident was deemed medically ready for a Spontaneous Breathing Trial (SBT), was the SBT performed by the second day of their Long Term Care Hospital (LTCH) stay?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"The question on the form assesses the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. The label for this section is 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"The patient's admission performance is evaluated based on their ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If the patient is managing an ostomy, the evaluation includes their ability to wipe the opening but not manage the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"The discharge goal for the patient is to have the ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"The patient's oral hygiene refers to their ability to use suitable items to clean their teeth. If applicable, the patient's ability to handle dentures includes inserting and removing dentures from their mouth and managing denture soaking and rinsing with the use of equipment. The discharge goal needs to be determined.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-11/K0200B","prefix":"K0200B","text":"The patient's weight in pounds should be based on the most recent measure taken in the last specified number of days. The weight must be measured consistently, in accordance with the standard practice of the facility or setting, which may include measurements in the morning after voiding, before meals, with shoes off, etc.","type":"integer","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"The form inquires about the patient's admission performance concerning their ability to roll from lying on their back to their left and right side, and then return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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If applicable, their use of dentures involves their ability to insert and remove dentures into and from the mouth, as well as manage denture soaking and rinsing with the use of equipment. This information was gathered from their performance upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. 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Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Please indicate the devices and aids that the patient or resident had used prior to their current illness, exacerbation, or injury. Check all that apply.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]}],"_id":"6ityct27teFj3MD9J"} {"responseType":"QuestionnaireResponse","id":"OASIS-DAH-D1-012020","questionnaire":"OASIS-DAH-D1-012020","title":"Outcome and Assessment Information Set - Death at Home","description":"Data set for use in home health agencies (HHAs), State agencies, software vendors, professional associations and other Federal agencies in implementing and maintaining OASIS.","status":"draft","authored":"2024-04-27T18:41:02.853Z","item":[{"linkId":"Section-21/M0080","prefix":"M0080","text":"The discipline of the person who is completing the assessment for the patient is required.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"RN"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"PT"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"SLP/ST"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"OT"}}]},{"linkId":"Section-21/M0090","prefix":"M0090","text":"The date the assessment was completed for the patient.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-21/M0100_","prefix":"M0100_","text":"This assessment is currently being completed for the following reason pertaining to the patient.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA6390-4","display":"Start of care - further visits planned"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6366-4","display":"Resumption of care (after inpatient stay)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6355-7","display":"Recertification (follow-up) reassessment"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6312-8","display":"Other follow-up"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6402-7","display":"Transferred to an inpatient facility - patient not discharged from agency"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6401-9","display":"Transferred to an inpatient facility - patient discharged from agency"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6179-1","display":"Death at home"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6184-1","display":"Discharge from agency"}}]},{"linkId":"Section-20/A0100A","prefix":"A0100A","text":"Does the patient have a National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-20/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-20/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0700","prefix":"A0700","text":"The patient's Medicaid number should be entered in the provided space. If the Medicaid application is pending, enter \"+\". If the patient is not a Medicaid recipient, enter \"N\".","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-20/A0800","prefix":"A0800","text":"What is the patient's gender? The possible answers are male, female, or prefer not to say.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}]},{"linkId":"Section-20/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0014","prefix":"M0014","text":"In which state does the patient currently reside?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-20/M0016","prefix":"M0016","text":"What is the patient's Branch ID Number?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-20/M0020","prefix":"M0020","text":"What is the patient's or resident's ID number?","type":"text","repeats":false,"readOnly":false,"maxLength":20},{"linkId":"Section-20/M0030","prefix":"M0030","text":"What is the start of care date for the patient?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0032","prefix":"M0032","text":"The date of the patient's resumption of care is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0050","prefix":"M0050","text":"What is the patient's state of residence?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-20/A0550","prefix":"A0550","text":"What is the patient's or resident's ZIP code?","type":"text","repeats":false,"readOnly":false,"maxLength":11},{"linkId":"Section-20/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-20/A0500C","prefix":"A0500C","text":"The patient's last name is required.","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-20/A0500D","prefix":"A0500D","text":"What is the patient's suffix?","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-35/M0906","prefix":"M0906","text":"The form asks for the date of the patient's or resident's discharge, transfer, or death at home to be entered in the \"Discharge/Transfer/Death Date\" field.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-31/N2005","prefix":"N2005","text":"Did the facility or setting contact and complete the actions prescribed or recommended by the physician, or the physician's designee, by midnight of the next calendar day each time potential clinically significant medication issues were identified for the patient since their admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27681-8","display":"NA-There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications"}}]},null,{"linkId":"Section-10/J1900A","prefix":"J1900A","text":"The patient exhibits no injury - there is no evidence of any injury noted on the physical assessment performed by the nurse or primary care clinician; the patient has made no complaints of pain or injury; moreover, there has been no change in the patient's behavior after the fall.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]},{"linkId":"Section-10/J1900B","prefix":"J1900B","text":"The form asks whether the patient has any minor injuries, including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains, or any fall-related injury that has caused them to complain of pain.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]},{"linkId":"Section-10/J1900C","prefix":"J1900C","text":"Has the patient had any major injuries such as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]}],"_id":"YNbYQWJshfg63cssq"} {"resourceType":"QuestionnaireResponse","id":"OASIS-E-012023-1","questionnaire":"OASIS-E-012023","title":"Outcome and Assessment Information Set (E)","status":"draft","authored":"2024-06-05T20:27:15.723Z","item":[{"repeats":false,"linkId":"Section A. Administrative Information /A1005","prefix":"A1005","readOnly":false,"text":"Ethnicity. Are you of Hispanic, Latino/a, or Spanish origin?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"No, not of Hispanic, Latino/a, or Spanish origin"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Yes, Mexican, Mexican American, Chicano/a"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Yes, Puerto Rican"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Yes, Cuban"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Yes, another Hispanic, Latino, or Spanish origin"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"{Patient/Resident/Person} unable to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"{Patient/Resident/Person} declines to respond"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A1010","prefix":"A1010","readOnly":false,"text":"Race. What is your race?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"White"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Asian Indian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Chinese"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Filipino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Japanese"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Korean"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Vietnamese"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Other Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"K","display":"Native Hawaiian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"L","display":"Guamanian or Chamorro"}},{"valueCoding":{"system":"http://del.cms.gov","code":"M","display":"Samoan"}},{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"{Patient/Resident/Person} unable to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"{Patient/Resident/Person} declines to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A1110","prefix":"A1110","readOnly":false,"text":"Language","type":"question"},{"repeats":false,"linkId":"Section A. Administrative Information /A1110A","prefix":"A1110A","readOnly":false,"text":"What is your preferred language?","type":"text"},{"repeats":false,"linkId":"Section A. Administrative Information /A1110B","prefix":"A1110B","readOnly":false,"text":"Do you need or want an interpreter to communicate with a doctor or health care staff?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Unable to determine"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A1250","prefix":"A1250","readOnly":false,"text":"Transportation (from NACHC). Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed from daily living? ","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Yes, it has kept me from medical appointments or from getting my medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"{Patient/Resident/Person} unable to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"{Patient/Resident/Person} declines to respond"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2120","prefix":"A2120","readOnly":false,"text":"Provision of Current Reconciled Medication List to Subsequent Provider at Transfer. At the time of transfer to another provider, did your agency provide the patient's current reconciled medication list to the subsequent provider?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - Current reconciled medication list not provided to the subsequent provider"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Current reconciled medication list provided to the subsequent provider"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"NA - The agency was not made aware of this transfer timely"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2121","prefix":"A2121","readOnly":false,"text":"Provision of Current Reconciled Medication List to Subsequent Provider at Discharge. At the time of discharge to another provider, did your agency provide the patient's current reconciled medication list to the subsequent provider?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - Current reconciled medication list not provided to the subsequent provider"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Current reconciled medication list provided to the subsequent provider"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2122","prefix":"A2122","readOnly":false,"text":"Route of Current Reconciled Medication List Transmission to Subsequent Provider. ","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Electronic Health Record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Health Information Exchange"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Verbal (e.g., in-person, telephone, video conferencing)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Paper-based (e.g., fax, copies, printouts)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Other Methods (e.g., texting, email, CDs)"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2123","prefix":"A2123","readOnly":false,"text":"Provision of Current Reconciled Medication List to Patient at Discharge. At the time of discharge, did your facility provide the patient's current reconciled medication list to the patient, family and/or caregiver?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - Current reconciled medication list not provided to the {patient/resident/person}, family and/or caregiver"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Current reconciled medication list provided to the {patient/resident/person}, family and/or caregiver"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2124","prefix":"A2124","readOnly":false,"text":"Route of Current Reconciled Medication List Transmission to Patient. Indicate the route(s) of transmission of the current reconciled medication list to the patient/family/caregiver.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Electronic Health Record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Health Information Exchange"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Verbal (e.g., in-person, telephone, video conferencing)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Paper-based (e.g., fax, copies, printouts)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Other Methods (e.g., texting, email, CDs)"}}]},{"repeats":false,"linkId":"Section B. Hearing, Speech, and Vision /B0200","prefix":"B0200","readOnly":false,"text":"Hearing. Ability to hear (with hearing aid or hearing appliances if normally used)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Adequate - no difficulty in normal conversation, social interaction, listening to TV"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Moderate difficulty - speaker has to increase volume and speak distinctly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Highly impaired - absence of useful hearing"}}]},{"repeats":false,"linkId":"Section B. Hearing, Speech, and Vision /B1000","prefix":"B1000","readOnly":false,"text":"Vision. Ability to see in adequate light (with glasses or other visual appliances)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Adequate - sees fine detail, such as regular print in newspapers/books"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Impaired - sees large print, but not regular print in newspapers/books"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Highly impaired - object identification in question, but eyes appear to follow objects"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects"}}]},{"repeats":false,"linkId":"Section B. Hearing, Speech, and Vision /B1300","prefix":"B1300","readOnly":false,"text":"Health Literacy. How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Often"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always"}},{"valueCoding":{"system":"http://del.cms.gov","code":"7","display":"{Patient/Resident/Person} declines to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"{Patient/Resident/Person} unable to respond"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0100","prefix":"C0100","readOnly":false,"text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all patients","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident/person} is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0200","prefix":"C0200","readOnly":false,"text":"Repetition of Three Words - Ask patient: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0300","prefix":"C0300","readOnly":false,"text":"Temporal Orientation (orientation to year, month, and day)","type":"question"},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0300A","prefix":"C0300A","readOnly":false,"text":"Ask patient: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0300B","prefix":"C0300B","readOnly":false,"text":"Ask patient: \"What month are we in right now?\" Able to report correct month","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0300C","prefix":"C0300C","readOnly":false,"text":"Ask patient: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0400","prefix":"C0400","readOnly":false,"text":"Recall. Ask patient: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"question"},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0400A","prefix":"C0400A","readOnly":false,"text":"Able to recall \"sock\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0400B","prefix":"C0400B","readOnly":false,"text":"Able to recall \"blue\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0400C","prefix":"C0400C","readOnly":false,"text":"Able to recall \"bed\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0500","prefix":"C0500","readOnly":false,"text":"BIMS Summary Score. Add scores for C0200-C0400 and fill in total score (00-15). Enter 99 if the patient was unable to complete the interview","type":"integer"},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310","prefix":"C1310","readOnly":false,"text":"Signs and Symptoms of Delirium (from CAM©)","type":"question"},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310A","prefix":"C1310A","readOnly":false,"text":"Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the patient's baseline?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310B","prefix":"C1310B","readOnly":false,"text":"Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Behavior not present"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Behavior continuously present, does not fluctuate"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Behavior present, fluctuates (comes and goes, changes in severity)"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310C","prefix":"C1310C","readOnly":false,"text":"Disorganized Thinking - Was the patient's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Behavior not present"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Behavior continuously present, does not fluctuate"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Behavior present, fluctuates (comes and goes, changes in severity)"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310D","prefix":"C1310D","readOnly":false,"text":"Altered Level of Consciousness - Did the patient have altered level of consciousness, as indicated by any of the following criteria? vigilant - startled easily to any sound or touch, lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch, stuporous - very difficult to arouse and keep aroused for the interview, comatose - could not be aroused","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Behavior not present"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Behavior continuously present, does not fluctuate"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Behavior present, fluctuates (comes and goes, changes in severity)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150","prefix":"D0150","readOnly":false,"text":"Patient Mood Interview (PHQ-2 to 9). Say to patient: \"Over the last 2 weeks, have you been bothered by any of the following problems?\"","type":"question"},{"repeats":false,"linkId":"Section D. Mood /D0150_1","prefix":"D0150_1","readOnly":false,"text":"Symptom Presence","type":"question"},{"repeats":false,"linkId":"Section D. Mood /D0150_2","prefix":"D0150_2","readOnly":false,"text":"Symptom Frequency","type":"question"},{"repeats":false,"linkId":"Section D. Mood /D0150A1","prefix":"D0150A1","readOnly":false,"text":"Little interest or pleasure in doing things - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150A2","prefix":"D0150A2","readOnly":false,"text":"Little interest of pleasure in doing things - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150B1","prefix":"D0150B1","readOnly":false,"text":"Feeling down, depressed, or hopeless - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150B2","prefix":"D0150B2","readOnly":false,"text":"Feeling down, depressed, or hopeless - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150C1","prefix":"D0150C1","readOnly":false,"text":"Trouble falling or staying asleep, or sleeping too much - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150C2","prefix":"D0150C2","readOnly":false,"text":"Trouble falling or staying asleep, or sleeping too much - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150D1","prefix":"D0150D1","readOnly":false,"text":"Feeling tired or having little energy - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150D2","prefix":"D0150D2","readOnly":false,"text":"Feeling tired or having little energy - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150E1","prefix":"D0150E1","readOnly":false,"text":"Poor appetite or overeating - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150E2","prefix":"D0150E2","readOnly":false,"text":"Poor appetite or overeating - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150F1","prefix":"D0150F1","readOnly":false,"text":"Feeling bad about yourself - or that you are a failure or have let yourself or your family down - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150F2","prefix":"D0150F2","readOnly":false,"text":"Feeling bad about yourself - or that you are a failure or have let yourself or your family down - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150G1","prefix":"D0150G1","readOnly":false,"text":"Trouble concentrating on things, such as reading the newspaper or watching television - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150G2","prefix":"D0150G2","readOnly":false,"text":"Trouble concentrating on things, such as reading the newspaper or watching television - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150H1","prefix":"D0150H1","readOnly":false,"text":"Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150H2","prefix":"D0150H2","readOnly":false,"text":"Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150I1","prefix":"D0150I1","readOnly":false,"text":"Thoughts that you would be better off dead, or of hurting yourself in some way - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150I2","prefix":"D0150I2","readOnly":false,"text":"Thoughts that you would be better off dead, or of hurting yourself in some way - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0160","prefix":"D0160","readOnly":false,"text":"Total Severity Score","type":"integer"},{"repeats":false,"linkId":"Section D. Mood /D0700","prefix":"D0700","readOnly":false,"text":"Social Isolation. How often do you feel lonely or isolated from those around you?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Often"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always"}},{"valueCoding":{"system":"http://del.cms.gov","code":"7","display":"{Patient/Resident/Person} declines to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"{Patient/Resident/Person} unable to respond"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100","prefix":"GG0100","readOnly":false,"text":"Prior Functioning: Everyday Activities. Indicate the patient's usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100A","prefix":"GG0100A","readOnly":false,"text":"Self-Care: Code the patient's need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident/Person} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident/Person} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100B","prefix":"GG0100B","readOnly":false,"text":"Indoor Mobility (Ambulation): Code the patient's need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident/Person} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident/Person} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100C","prefix":"GG0100C","readOnly":false,"text":"Stairs: Code the patient's need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident/Person} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident/Person} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100D","prefix":"GG0100D","readOnly":false,"text":"Functional Cognition: Code the patient's need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident/Person} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident/Person} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0110","prefix":"GG0110","readOnly":false,"text":"Prior Device Use. Indicate devices and aids used by the patient prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130","prefix":"GG0130","readOnly":false,"text":"Self-Care","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130_1","prefix":"GG0130_1","readOnly":false,"text":"Self-Care. Code the patient's usual performance at SOC/ROC for each activity using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130_2","prefix":"GG0130_2","readOnly":false,"text":"Self-Care. Code the patient's discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s).","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130_3","prefix":"GG0130_3","readOnly":false,"text":"Self-Care. Code the patient's usual performance at discharge for each activity using the 6-point scale. If any activity was not attempted at discharge, code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130_4","prefix":"GG0130_4","readOnly":false,"text":"Self-Care. Code the patient's usual performance at Follow-Up for each activity using the 6-point scale. If activity was not attempted at Follow-Up code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130A1","prefix":"GG0130A1","readOnly":false,"text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130A2","prefix":"GG0130A2","readOnly":false,"text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130A3","prefix":"GG0130A3","readOnly":false,"text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130A4","prefix":"GG0130A4","readOnly":false,"text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. - Follow-up Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130B1","prefix":"GG0130B1","readOnly":false,"text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130B2","prefix":"GG0130B2","readOnly":false,"text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130B3","prefix":"GG0130B3","readOnly":false,"text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130B4","prefix":"GG0130B4","readOnly":false,"text":"Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Follow-up Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130C1","prefix":"GG0130C1","readOnly":false,"text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. 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Functional Abilities and Goals/GG0130E1","prefix":"GG0130E1","readOnly":false,"text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. 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Functional Abilities and Goals/GG0130E2","prefix":"GG0130E2","readOnly":false,"text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130E3","prefix":"GG0130E3","readOnly":false,"text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130E4","prefix":"GG0130E4","readOnly":false,"text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130F1","prefix":"GG0130F1","readOnly":false,"text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130F2","prefix":"GG0130F2","readOnly":false,"text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130F3","prefix":"GG0130F3","readOnly":false,"text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130F4","prefix":"GG0130F4","readOnly":false,"text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130G1","prefix":"GG0130G1","readOnly":false,"text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130G2","prefix":"GG0130G2","readOnly":false,"text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130G3","prefix":"GG0130G3","readOnly":false,"text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130G4","prefix":"GG0130G4","readOnly":false,"text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130H1","prefix":"GG0130H1","readOnly":false,"text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130H2","prefix":"GG0130H2","readOnly":false,"text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130H3","prefix":"GG0130H3","readOnly":false,"text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130H4","prefix":"GG0130H4","readOnly":false,"text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170","prefix":"GG0170","readOnly":false,"text":"Mobility","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170_1","prefix":"GG0170_1","readOnly":false,"text":"Mobility. Code the patient's usual performance at SOC/ROC for each activity using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170_2","prefix":"GG0170_2","readOnly":false,"text":"Mobility. Code the patient's discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s).","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170_3","prefix":"GG0170_3","readOnly":false,"text":"Mobility. Code the patient's usual performance at discharge for each activity using the 6-point scale. If an activity was not attempted at discharge, code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170_4","prefix":"GG0170_4","readOnly":false,"text":"Mobility. Code the patient's usual performance at Follow-up for each activity using the 6-point scale. If activity was not attempted at Follow-up code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170A1","prefix":"GG0170A1","readOnly":false,"text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170A2","prefix":"GG0170A2","readOnly":false,"text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170A3","prefix":"GG0170A3","readOnly":false,"text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170A4","prefix":"GG0170A4","readOnly":false,"text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Follow-up Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170B1","prefix":"GG0170B1","readOnly":false,"text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. 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Functional Abilities and Goals/GG0170R1","prefix":"GG0170R1","readOnly":false,"text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170R2","prefix":"GG0170R2","readOnly":false,"text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170R3","prefix":"GG0170R3","readOnly":false,"text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170R4","prefix":"GG0170R4","readOnly":false,"text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Follow-up Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170RR1","prefix":"GG0170RR1","readOnly":false,"text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170RR3","prefix":"GG0170RR3","readOnly":false,"text":"Indicate the type of wheelchair or scooter used. - Discharge","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170S1","prefix":"GG0170S1","readOnly":false,"text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170S2","prefix":"GG0170S2","readOnly":false,"text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170S3","prefix":"GG0170S3","readOnly":false,"text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170SS1","prefix":"GG0170SS1","readOnly":false,"text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170SS3","prefix":"GG0170SS3","readOnly":false,"text":"Indicate the type of wheelchair or scooter used. - Discharge","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J0510","prefix":"J0510","readOnly":false,"text":"Pain Effect on Sleep. Ask patient: \"Over the past 5 days, how much of the time has pain made it hard for you to sleep at night?\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Does not apply - I have not had any pain or hurting in the past 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely or not at all"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Occasionally"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Frequently"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Almost constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unable to answer"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J0520","prefix":"J0520","readOnly":false,"text":"Pain Interference with Therapy Activities. Ask patient: \"Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain?\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Does not apply - I have not received rehabilitation therapy in the past 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely or not at all"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Occasionally"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Frequently"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Almost constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unable to answer"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J0530","prefix":"J0530","readOnly":false,"text":"Pain Interference with Day-to-Day Activities. Ask patient: \"Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain?\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely or not at all"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Occasionally"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Frequently"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Almost constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unable to answer"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J1800","prefix":"J1800","readOnly":false,"text":"Has the patient had any falls since SOC/ROC, whichever is more recent?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J1900","prefix":"J1900","readOnly":false,"text":"Number of Falls Since SOC/ROC, whichever is most recent","type":"question"},{"repeats":false,"linkId":"Section J. Health Conditions/J1900A","prefix":"J1900A","readOnly":false,"text":"No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two or more"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J1900B","prefix":"J1900B","readOnly":false,"text":"Injury (except major): skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two or more"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J1900C","prefix":"J1900C","readOnly":false,"text":"Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two or more"}}]},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/K0520","prefix":"K0520","readOnly":false,"text":"Nutritional Approaches","type":"question"},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/K0520_1","prefix":"K0520_1","readOnly":false,"text":"Check all of the following nutritional approaches that apply on {admission}","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Parenteral/IV feeding"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Feeding tube (e.g., nasogastric or abdominal (PEG))"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Therapeutic diet (e.g., low salt, diabetic, low cholesterol)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/K0520_4","prefix":"K0520_4","readOnly":false,"text":"Check all of the nutritional approaches that were received in the last 7 days","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Parenteral/IV feeding"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Feeding tube (e.g., nasogastric or abdominal (PEG))"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Therapeutic diet (e.g., low salt, diabetic, low cholesterol)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section K. 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Active Diagnoses/M1023_E2_ICD","prefix":"M1023_E2_ICD","readOnly":false,"text":"Other Diagnosis e.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (no diagnosis code)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"ICD","display":"ICD-10 diagnosis code"}}]},{"repeats":false,"linkId":"Section I. Active Diagnoses/M1023_E2_SEV","prefix":"M1023_E2_SEV","readOnly":false,"text":"Symptom Control Rating e.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"No severity rating"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Asymptomatic, no treatment needed at this time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Symptoms well controlled with current therapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Symptoms controlled with difficulty, affecting daily functioning; {patient/resident/person} needs ongoing monitoring"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Symptoms poorly controlled: {patient/resident/person} needs frequent adjustment in treatment and dose monitoring"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Symptoms poorly controlled: history of re-hospitalizations"}}]},{"repeats":false,"linkId":"Section I. Active Diagnoses/M1023_F2_ICD","prefix":"M1023_F2_ICD","readOnly":false,"text":"Other Diagnosis f.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (no diagnosis code)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"ICD","display":"ICD-10 diagnosis code"}}]},{"repeats":false,"linkId":"Section I. Active Diagnoses/M1023_F2_SEV","prefix":"M1023_F2_SEV","readOnly":false,"text":"Symptom Control Rating f.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"No severity rating"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Asymptomatic, no treatment needed at this time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Symptoms well controlled with current therapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Symptoms controlled with difficulty, affecting daily functioning; {patient/resident/person} needs ongoing monitoring"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Symptoms poorly controlled: {patient/resident/person} needs frequent adjustment in treatment and dose monitoring"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Symptoms poorly controlled: history of re-hospitalizations"}}]},{"repeats":false,"linkId":"Section I. Active Diagnoses/M1028","prefix":"M1028","readOnly":false,"text":"Active Diagnoses - Comorbidities and Co-existing Conditions: Check all that apply. See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Diabetes Mellitus (DM)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"None of the above"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/M1033","prefix":"M1033","readOnly":false,"text":"Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? Check all that apply","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"History of falls (2 or more falls - or any fall with an injury - in the past 12 months)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unintentional weight loss of a total of 10 pounds or more in the past 12 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Multiple hospitalizations (2 or more) in the past 6 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Multiple emergency department visits (2 or more) in the past 6 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Decline in mental, emotional, or behavioral status in the past 3 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"Currently taking 5 or more medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"Currently reports exhaustion"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Other risk(s) not listed in 1 - 8"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"None of the above"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/M1041","prefix":"M1041","readOnly":false,"text":"Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/M1046","prefix":"M1046","readOnly":false,"text":"Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year's flu season?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Yes; received from another health care provider (for example, physician, pharmacist)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"No; {patient/resident/person} offered and declined"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No; {patient/resident/person} assessed and determined to have medical contraindication(s)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"No; not indicated - {patient/resident/person} does not meet age/condition guidelines for influenza vaccine"}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"No; inability to obtain vaccine due to declared shortage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"No; {patient/resident/person} did not receive the vaccine due to reasons other than those listed in responses 4 - 7"}}]},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/M1060","prefix":"M1060","readOnly":false,"text":"Height and Weight. While measuring, if the number is X.1-X.4 round down, X.5 or greater round up","type":"question"},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/M1060_A","prefix":"M1060_A","readOnly":false,"text":"Height (in inches). Record most recent height measure since the most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/M1060_B","prefix":"M1060_B","readOnly":false,"text":"Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to standard agency practice (for example, in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer"},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M1100","prefix":"M1100","readOnly":false,"text":"Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only.)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident/Person} lives alone, around the clock assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident/Person} lives alone, regular daytime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} lives alone, regular nighttime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident/Person} lives alone, occasional / short-term assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident/Person} lives alone, no assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"{Patient/Resident/Person} lives with other person(s) in the home, around the clock assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} lives with other person(s) in the home, regular daytime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"{Patient/Resident/Person} lives with other person(s) in the home, regular nighttime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"{Patient/Resident/Person} lives with other person(s) in the home, occasional/short-term assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"{Patient/Resident/Person} lives with other person(s) in the home, no assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), around the clock assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"12","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), regular daytime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"13","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), regular nighttime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"14","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), occasional / short-term assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"15","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), no assistance available."}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1306","prefix":"M1306","readOnly":false,"text":"Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? (Excludes Stage 1 pressure injuries and all healed pressure ulcers/injuries)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1307","prefix":"M1307","readOnly":false,"text":"The Oldest Stage 2 Pressure Ulcer that is present at discharge: (Excludes healed Stage 2 Pressure Ulcers)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Was present at the most recent SOC/ROC assessment"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Developed since the most recent SOC/ROC assessment"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"No Stage 2 pressure ulcers are present at discharge"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1307_DT","prefix":"M1307_DT","readOnly":false,"text":"Record date pressure ulcer first identified","type":"date"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311","prefix":"M1311","readOnly":false,"text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Admission","type":"question"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_A1","prefix":"M1311_A1","readOnly":false,"text":"Number of Stage 2 pressure ulcers","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_A2","prefix":"M1311_A2","readOnly":false,"text":"Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_B1","prefix":"M1311_B1","readOnly":false,"text":"Number of Stage 3 pressure ulcers","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_B2","prefix":"M1311_B2","readOnly":false,"text":"Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_C1","prefix":"M1311_C1","readOnly":false,"text":"Number of Stage 4 pressure ulcers","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_C2","prefix":"M1311_C2","readOnly":false,"text":"Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_D1","prefix":"M1311_D1","readOnly":false,"text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_D2","prefix":"M1311_D2","readOnly":false,"text":"Number of these unstageable pressure ulcers/injuries that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_E1","prefix":"M1311_E1","readOnly":false,"text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_E2","prefix":"M1311_E2","readOnly":false,"text":"Number of these unstageable pressure ulcers that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_F1","prefix":"M1311_F1","readOnly":false,"text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_F2","prefix":"M1311_F2","readOnly":false,"text":"Number of these unstageable pressure injuries that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1322","prefix":"M1322","readOnly":false,"text":"Current Number of Stage 1 Pressure Injuries. Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"0"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"1"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"2"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"3"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"4 or more"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1324","prefix":"M1324","readOnly":false,"text":"Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable. Excludes pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar, or deep tissue injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Stage 1"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Stage 2"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Stage 3"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Stage 4"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} has no pressure ulcers/injuries or no stageable pressure ulcers/injuries"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1330","prefix":"M1330","readOnly":false,"text":"Does this patient have a Stasis Ulcer?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes, {patient/resident/person} has BOTH observable and unobservable stasis ulcers."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Yes, {patient/resident/person} has observable stasis ulcers ONLY."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Yes, {patient/resident/person} has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing/device)"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1332","prefix":"M1332","readOnly":false,"text":"Current Number of Stasis Ulcer(s) that are Observable","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Four or more"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1334","prefix":"M1334","readOnly":false,"text":"Status of Most Problematic Stasis Ulcer that is Observable","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Fully granulating"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Early/partial granulation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Not healing"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1340","prefix":"M1340","readOnly":false,"text":"Does this patient have a Surgical Wound?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes, {patient/resident/person} has at least one observable surgical wound"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Surgical wound known but not observable due to non-removable dressing/device"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1342","prefix":"M1342","readOnly":false,"text":"Status of Most Problematic Surgical Wound that is Observable","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Newly epithelialized"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Fully granulating"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Early/partial granulation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Not healing"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/M1400","prefix":"M1400","readOnly":false,"text":"When is the patient dyspneic or noticeably Short of Breath?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"{Patient/Resident/Person} is not short of breath"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"When walking more than 20 feet, climbing stairs"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"With moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than 20 feet)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"With minimal exertion (for example, while eating, talking, or performing other ADLs) or with agitation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"At rest (during day or night)"}}]},{"repeats":false,"linkId":"Section H. Bladder and Bowel/M1600","prefix":"M1600","readOnly":false,"text":"Has this patient been treated for a Urinary Tract Infection in the past 14 days?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} on prophylactic treatment"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Unknown"}}]},{"repeats":false,"linkId":"Section H. Bladder and Bowel/M1610","prefix":"M1610","readOnly":false,"text":"Urinary Incontinence or Urinary Catheter Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No incontinence or catheter (includes anuria or ostomy for urinary drainage)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident/Person} is incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident/Person} requires a urinary catheter (specifically: external, indwelling, intermittent, or suprapubic)"}}]},{"repeats":false,"linkId":"Section H. Bladder and Bowel/M1620","prefix":"M1620","readOnly":false,"text":"Bowel Incontinence Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Very rarely or never has bowel incontinence"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Less than once weekly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"One to three times weekly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Four to six times weekly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"On a daily basis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"More often than once daily"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} has ostomy for bowel elimination"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Unknown"}}]},{"repeats":false,"linkId":"Section H. Bladder and Bowel/M1630","prefix":"M1630","readOnly":false,"text":"Ostomy for Bowel Elimination. Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay; or b) necessitated a change in medical or treatment regimen?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"{Patient/Resident/Person} does not have an ostomy for bowel elimination."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient's/Resident's} ostomy was not related to an inpatient stay and did not necessitate change in medical or treatment regimen."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"The ostomy was related to an inpatient stay or did necessitate change in medical or treatment regimen."}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /M1700","prefix":"M1700","readOnly":false,"text":"Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Requires assistance and some direction in specific situations (for example, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Requires considerable assistance in routine situations. Is not alert and oriented or is unable to shift attention and recall directions more than half the time."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium."}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /M1710","prefix":"M1710","readOnly":false,"text":"When Confused. Reported or Observed Within the Last 14 Days.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Never"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"In new or complex situations only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"On awakening or at night only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"During the day and evening, but not constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} nonresponsive"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /M1720","prefix":"M1720","readOnly":false,"text":"When Anxious. Reported or Observed Within the Last 14 Days.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"None of the time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Less often than daily"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Daily, but not constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"All of the time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} nonresponsive"}}]},{"repeats":false,"linkId":"Section E. Behavior /M1740","prefix":"M1740","readOnly":false,"text":"Cognitive, Behavioral, and Psychiatric symptoms that are demonstrated at least once a week (Reported or Observed). Check all that apply","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Memory deficit: failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Verbal disruption: yelling, threatening, excessive profanity, sexual references, etc."}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Physical aggression: aggressive or combative to self and others (for example, hits self, throws objects, punches, dangerous maneuvers with wheelchair or other objects)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Disruptive, infantile, or socially inappropriate behavior (excludes verbal actions)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"6","display":"Delusional, hallucinatory, or paranoid behavior"}},{"valueCoding":{"system":"http://del.cms.gov","code":"7","display":"None of the above behaviors demonstrated"}}]},{"repeats":false,"linkId":"Section E. Behavior /M1745","prefix":"M1745","readOnly":false,"text":"Frequency of Disruptive Behavior Symptoms (Reported or Observed). Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Never"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Less than once a month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Once a month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Several times each month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Several times a week"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"At least daily"}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1800","prefix":"M1800","readOnly":false,"text":"Grooming. Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care).","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to groom self unaided, with or without the use of assistive devices or adapted methods."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Grooming utensils must be placed within reach before able to complete grooming activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Someone must assist the {patient/resident/person} to groom self."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} depends entirely upon someone else for grooming needs."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1810","prefix":"M1810","readOnly":false,"text":"Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons and snaps.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to dress upper body without assistance if clothing is laid out or handed to the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Someone must help the {patient/resident/person} put on upper body clothing."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} depends entirely upon another person to dress the upper body."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1820","prefix":"M1820","readOnly":false,"text":"Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to obtain, put on, and remove clothing and shoes without assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to dress lower body without assistance if clothing and shoes are laid out or handed to the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Someone must help the {patient/resident/person} put on undergarments, slacks, socks or nylons, and shoes."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} depends entirely upon another person to dress lower body."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1830","prefix":"M1830","readOnly":false,"text":"Bathing. Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to bathe self in shower or tub independently, including getting in and out of tub/shower."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of the tub/shower."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Unable to participate effectively in bathing and is bathed totally by another person."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1840","prefix":"M1840","readOnly":false,"text":"Toilet Transferring. Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to get to and from the toilet and transfer independently with or without a device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Is totally dependent in toileting."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1845","prefix":"M1845","readOnly":false,"text":"Toileting Hygiene. Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to manage toileting hygiene and clothing management without assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Someone must help the {patient/resident/person} to maintain toileting hygiene and/or adjust clothing."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} depends entirely upon another person to maintain toileting hygiene."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1850","prefix":"M1850","readOnly":false,"text":"Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently transfer."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to transfer with minimal human assistance or with use of an assistive device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Able to bear weight and pivot during the transfer process but unable to transfer self."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Unable to transfer self and is unable to bear weight or pivot when transferred by another person."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Bedfast, unable to transfer but is able to turn and position self in bed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Bedfast, unable to transfer and is unable to turn and position self."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1860","prefix":"M1860","readOnly":false,"text":"Ambulation/Locomotion. Current ability to walk safely, once in a standing position, or use a wheelchair, once in in a seated position, on a variety of surfaces.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (specifically: needs no human assistance or assistive device)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Requires use of a two-handed device (for example, walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Able to walk only with the supervision or assistance of another person at all times."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Chairfast, unable to ambulate but is able to wheel self independently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Chairfast, unable to ambulate and is unable to wheel self."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Bedfast, unable to ambulate or be up in a chair."}}]},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/M1870","prefix":"M1870","readOnly":false,"text":"Feeding or Eating. Current ability to feed self meals and snacks safely. Note: This refers only to the process of eating, chewing, and swallowing, not preparing the food to be eaten.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently feed self."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to feed self independently but requires: (a) meal set-up; OR (b) intermittent assistance or supervision from another person; OR (c) a liquid, pureed or ground meat diet."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unable to feed self and must be assisted or supervised throughout the meal/snack."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Able to take in nutrients orally and receives supplemental nutrients though a nasogastric tube or gastrostomy."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Unable to take in nutrients orally or by tube feeding."}}]},{"repeats":false,"linkId":"Section N. Medications /M2001","prefix":"M2001","readOnly":false,"text":"Drug Regimen Review. Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident/Person} is not taking any medications"}}]},{"repeats":false,"linkId":"Section N. Medications /M2003","prefix":"M2003","readOnly":false,"text":"Medication Follow-up. Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section N. Medications /M2005","prefix":"M2005","readOnly":false,"text":"Medication Intervention. Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - There were no potential clinically significant medication issues identified since {admission} or {patient/resident/person} is not taking any medications"}}]},{"repeats":false,"linkId":"Section N. Medications /M2010","prefix":"M2010","readOnly":false,"text":"Patient/Caregiver High-Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} not taking any high-risk drugs OR {patient/resident/person}/caregiver fully knowledgeable about special precautions associated with all high-risk medications"}}]},{"repeats":false,"linkId":"Section N. Medications /M2016","prefix":"M2016","readOnly":false,"text":"Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} not taking any drugs"}}]},{"repeats":false,"linkId":"Section N. Medications /M2020","prefix":"M2020","readOnly":false,"text":"Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. Excludes injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness.)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Able to take medication(s) at the correct times if given reminders by another person at the appropriate times"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Unable to take medication unless administered by another person."}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"No oral medications prescribed."}}]},{"repeats":false,"linkId":"Section N. Medications /M2030","prefix":"M2030","readOnly":false,"text":"Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. Excludes IV medications.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently take the correct medication(s) and proper dosage(s) at the correct times."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Unable to take injectable medication unless administered by another person."}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"No injectable medications prescribed."}}]},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102","prefix":"M2102","readOnly":false,"text":"Types and Sources of Assistance. Determine the ability and willingness of non-agency caregivers (such as family members, friends, or privately paid caregivers) to provide assistance for the following activities, if assistance is needed. Excludes all care by your agency staff.","type":"question"},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102_A","prefix":"M2102_A","readOnly":false,"text":"ADL assistance (for example, transfer/ambulation, bathing, dressing, toileting, eating/feeding)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No assistance needed - {patient/resident/person} is independent or does not have needs in this area"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Non-agency caregiver(s) currently provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Non-agency caregiver(s) need training/supportive services to provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Assistance needed, but no non-agency caregiver(s) available"}}]},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102_C","prefix":"M2102_C","readOnly":false,"text":"Medication administration (for example, oral, inhaled or injectable)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No assistance needed - {patient/resident/person} is independent or does not have needs in this area"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Non-agency caregiver(s) currently provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Non-agency caregiver(s) need training/supportive services to provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Assistance needed, but no non-agency caregiver(s) available"}}]},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102_D","prefix":"M2102_D","readOnly":false,"text":"Medical procedures/treatments (for example, changing wound dressing, home exercise program)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No assistance needed - {patient/resident/person} is independent or does not have needs in this area"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Non-agency caregiver(s) currently provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Non-agency caregiver(s) need training/supportive services to provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Assistance needed, but no non-agency caregiver(s) available"}}]},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102_F","prefix":"M2102_F","readOnly":false,"text":"Supervision and safety (for example, due to cognitive impairment)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No assistance needed - {patient/resident/person} is independent or does not have needs in this area"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Non-agency caregiver(s) currently provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Non-agency caregiver(s) need training/supportive services to provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Assistance needed, but no non-agency caregiver(s) available"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/M2200","prefix":"M2200","readOnly":false,"text":"Therapy Need. In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits (total of reasonable and necessary physical, occupational, and speech-language pathology visits combined)? Enter zero [\"000\"] if no therapy visits indicated.","type":"integer"},{"repeats":false,"linkId":"Section A. Administrative Information /M2301","prefix":"M2301","readOnly":false,"text":"Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes, used hospital emergency department WITHOUT hospital admission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Yes, used hospital emergency department WITH hospital admission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Unknown"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /M2310","prefix":"M2310","readOnly":false,"text":"Reason for Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or without hospitalization)? (Check all that apply)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Improper medication administration, adverse drug reactions, medication side effects, toxicity, anaphylaxis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Hypo/Hyperglycemia, diabetes out of control"}},{"valueCoding":{"system":"http://del.cms.gov","code":"19","display":"Other than above reasons"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Reason unknown"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401","prefix":"M2401","readOnly":false,"text":"Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? (Check only one box in each row)","type":"question"},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_B","prefix":"M2401_B","readOnly":false,"text":"Falls prevention interventions","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_C","prefix":"M2401_C","readOnly":false,"text":"Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_D","prefix":"M2401_D","readOnly":false,"text":"Intervention(s) to monitor and mitigate pain","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_E","prefix":"M2401_E","readOnly":false,"text":"Intervention(s) to prevent pressure ulcers","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_F","prefix":"M2401_F","readOnly":false,"text":"Pressure ulcer treatment based on principles of moist wound healing","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /M2410","prefix":"M2410","readOnly":false,"text":"To which Inpatient Facility has the patient been admitted?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Rehabilitation facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Nursing home"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Hospice"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"No inpatient facility admission"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /M2420","prefix":"M2420","readOnly":false,"text":"Discharge Disposition: Where is the patient after discharge from your agency? Choose only one answer","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident/Person} remained in the community (without formal assistive services)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident/Person} remained in the community (with formal assistive services)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} transferred to a non-institutional hospice"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unknown because {patient/resident/person} moved to a geographic location not served by this agency"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Other unknown"}}]},{"repeats":false,"linkId":"Section N. Medications /N0415","prefix":"N0415","readOnly":false,"text":"High-Risk Drug Classes: Use and Indication","type":"question"},{"repeats":false,"linkId":"Section N. Medications /N0415_1","prefix":"N0415_1","readOnly":false,"text":"Check if the patient is taking any medications by pharmacological classification, not how it is used, in the following classes","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Antipsychotic"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Anticoagulant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Antibiotic"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Opioid"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Antiplatelet"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Hypoglycemic (including insulin)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section N. Medications /N0415_2","prefix":"N0415_2","readOnly":false,"text":"High-Risk Drug Classes: Use and Indication - Indication noted","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Antipsychotic"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Anticoagulant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Antibiotic"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Opioid"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Antiplatelet"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Hypoglycemic (including insulin)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/O0110","prefix":"O0110","readOnly":false,"text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that apply.","type":"question"},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/O0110_a","prefix":"O0110_a","readOnly":false,"text":"Special Treatments, Procedures, and Programs - On Admission","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A1","display":"Chemotherapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A10","display":"Chemotherapy - Other"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A2","display":"Chemotherapy - IV"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A3","display":"Chemotherapy - Oral"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B1","display":"Radiation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C1","display":"Oxygen Therapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C2","display":"Oxygen Therapy - Continuous"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C3","display":"Oxygen Therapy - Intermittent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C4","display":"Oxygen Therapy - High-concentration"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D1","display":"Suctioning"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D2","display":"Suctioning - Scheduled"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D3","display":"Suctioning - As Needed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E1","display":"Tracheostomy care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F1","display":"Invasive Mechanical Ventilator (ventilator or respirator)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G1","display":"Non-Invasive Mechanical Ventilator"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G2","display":"Non-Invasive Mechanical Ventilator - BiPAP"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G3","display":"Non-Invasive Mechanical Ventilator - CPAP"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H1","display":"IV Medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H10","display":"IV Medications - Other"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H2","display":"IV Medications - Vasoactive medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H3","display":"IV Medications - Antibiotics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H4","display":"IV Medications - Anticoagulant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1","display":"Transfusions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J1","display":"Dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J2","display":"Dialysis - Hemodialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J3","display":"Dialysis - Peritoneal dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O1","display":"IV Access"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O2","display":"IV Access - Peripheral"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O3","display":"IV Access - Midline"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O4","display":"IV Access - Central (e.g., PICC, tunneled, port)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z1","display":"None of the Above"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/O0110_c","prefix":"O0110_c","readOnly":false,"text":"Special Treatments, Procedures, and Programs - At Discharge","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A1","display":"Chemotherapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A10","display":"Chemotherapy - Other"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A2","display":"Chemotherapy - IV"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A3","display":"Chemotherapy - Oral"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B1","display":"Radiation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C1","display":"Oxygen Therapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C2","display":"Oxygen Therapy - Continuous"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C3","display":"Oxygen Therapy - Intermittent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C4","display":"Oxygen Therapy - High-concentration"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D1","display":"Suctioning"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D2","display":"Suctioning - Scheduled"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D3","display":"Suctioning - As Needed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E1","display":"Tracheostomy care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F1","display":"Invasive Mechanical Ventilator (ventilator or respirator)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G1","display":"Non-Invasive Mechanical Ventilator"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G2","display":"Non-Invasive Mechanical Ventilator - BiPAP"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G3","display":"Non-Invasive Mechanical Ventilator - CPAP"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H1","display":"IV Medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H10","display":"IV Medications - Other"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H2","display":"IV Medications - Vasoactive medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H3","display":"IV Medications - Antibiotics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H4","display":"IV Medications - Anticoagulant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1","display":"Transfusions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J1","display":"Dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J2","display":"Dialysis - Hemodialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J3","display":"Dialysis - Peritoneal dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O1","display":"IV Access"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O2","display":"IV Access - Peripheral"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O3","display":"IV Access - Midline"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O4","display":"IV Access - Central (e.g., PICC, tunneled, port)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z1","display":"None of the Above"}}]}],"_id":"N7YfwSRxy7EE9Cwqc"} {"responseType":"QuestionnaireResponse","questionnaire":"HIS-HA-2.00.0","id":"HIS-HA-2.00.0-1","title":"Hospice Item Set - Hospice Admission Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-09-20T06:29:57.933Z","item":[{"linkId":"Section-36","text":"Section A: Administrative Information","type":"group","readOnly":true,"item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0"},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3"},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5"},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Admitted From. Immediately preceding this admission, where was the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.6"},{"linkId":"Section-36/A0550","prefix":"A0550","text":"{Patient/Resident} ZIP Code.","type":"text","repeats":false,"readOnly":false,"maxLength":11,"id":"item.0.item.7"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1"}],"id":"item.0.item.8"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3"}],"id":"item.0.item.9"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1"}],"id":"item.0.item.10"},{"linkId":"Section-36/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.11"},{"linkId":"Section-36/A1400","prefix":"A1400","text":"Payer Information: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.12"},{"linkId":"Section-36/A0205","prefix":"A0205","text":"Site of Service at Admission","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.13"},{"linkId":"Section-36/A0245","prefix":"A0245","text":"Date Initial Nursing Assessment Initiated","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.14"}],"id":"item.0","description":"The patient must fill out Section A, which pertains to administrative information."},{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0","description":"The form asks the patient to enter their Medicaid number. If their Medicaid is still pending, they should enter \"+\". If they are not a Medicaid recipient, they should enter \"N\"."},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1","description":"What is the patient's gender? The options are male, female, or prefer not to say."},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2","description":"What is the patient's date of birth?"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3","description":"The type of record for the patient needs to be identified."},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4","description":"What is the reason for the patient's assessment?"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5","description":"What is the patient's admission date?"},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Admitted From. Immediately preceding this admission, where was the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.6","description":"Where was the patient immediately preceding this admission? Was the patient admitted from their home, another hospital, a nursing home, or somewhere else?"},{"linkId":"Section-36/A0550","prefix":"A0550","text":"{Patient/Resident} ZIP Code.","type":"text","repeats":false,"readOnly":false,"maxLength":11,"id":"item.0.item.7","description":"What is the patient's or resident's ZIP code?"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1"}],"id":"item.0.item.8","description":"The patient needs to provide the numbers associated with their facility provider."},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0","description":"What is the patient's National Provider Identifier (NPI)?"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1","description":"What is the patient's CMS Certification Number (CCN)?"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3"}],"id":"item.0.item.9","description":"What is the legal name of the patient or resident?"},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0","description":"What is the patient's first name?"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1","description":"What is the patient's middle initial?"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last 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numbers."},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0","description":"What is the patient's Social Security Number?"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1","description":"What is the patient's Medicare number?"},{"linkId":"Section-36/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.11","description":"The patient must check all the boxes that apply to their race or ethnicity."},{"linkId":"Section-36/A1400","prefix":"A1400","text":"Payer Information: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.12","description":"The patient should provide all applicable payer information by checking all the relevant options."},{"linkId":"Section-36/A0205","prefix":"A0205","text":"Site of Service at Admission","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.13","description":"What was the patient's site of service at the time of admission?"},{"linkId":"Section-36/A0245","prefix":"A0245","text":"Date Initial Nursing Assessment Initiated","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.14","description":"The date the initial nursing assessment for the patient was initiated."},{"linkId":"Section-47","text":"Section F: Preferences","type":"group","readOnly":true,"item":[{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0"},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1"}],"id":"item.1.item.0"},{"linkId":"Section-47/F2100","prefix":"F2100","text":"Other Life-Sustaining Treatment Preferences","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0"},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1"}],"id":"item.1.item.1"},{"linkId":"Section-47/F2200","prefix":"F2200","text":"Hospitalization Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0"},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1"}],"id":"item.1.item.2"},{"linkId":"Section-47/F3000","prefix":"F3000","text":"Spiritual/Existential Concerns","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0"},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1"}],"id":"item.1.item.3"}],"id":"item.1","description":"In section F of the form, the patient's preferences are discussed."},{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0"},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1"}],"id":"item.1.item.0","description":"Does the patient have a preference regarding CPR?"},{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0","description":"Was the patient, or the responsible party, asked about their preference regarding the use of cardiopulmonary resuscitation (CPR)? Please select the most accurate response."},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1","description":"The date when the patient or responsible party was first asked about their preference regarding the use of CPR."},{"linkId":"Section-47/F2100","prefix":"F2100","text":"Other Life-Sustaining Treatment Preferences","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0"},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1"}],"id":"item.1.item.1","description":"Does the patient have other life-sustaining treatment preferences?"},{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0","description":"Was the patient or responsible party asked about their preferences regarding life-sustaining treatments other than CPR? Please select the most accurate response."},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1","description":"The date on which the patient or responsible party was first asked about their preferences regarding life-sustaining treatments other than Cardiopulmonary Resuscitation was:"},{"linkId":"Section-47/F2200","prefix":"F2200","text":"Hospitalization Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0"},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1"}],"id":"item.1.item.2","description":"The patient has to choose their hospitalization preference."},{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0","description":"Was the patient or the responsible party asked about their preference regarding hospitalization? Please select the most accurate response."},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1","description":"The date that the patient, resident, or responsible party was first asked about their preference regarding hospitalization was:"},{"linkId":"Section-47/F3000","prefix":"F3000","text":"Spiritual/Existential Concerns","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0"},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1"}],"id":"item.1.item.3","description":"Does the patient have any spiritual or existential concerns?"},{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0","description":"Was the patient or resident and/or their caregiver asked about any spiritual or existential concerns? Please select the most accurate response."},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1","description":"When was the patient or their caregiver first asked about their spiritual or existential concerns?"},{"linkId":"Section-9","text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal Diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"}],"id":"item.2","description":"In Section I of the form, the patient's active diagnoses are listed."},{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal Diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"What is the patient's principal diagnosis?"},{"linkId":"Section-10","text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J0900","prefix":"J0900","text":"Pain Screening","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3"}],"id":"item.3.item.0"},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Pain Active Problem. Is pain an active problem for the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.1"},{"linkId":"Section-10/J0910","prefix":"J0910","text":"Comprehensive Pain Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2"}],"id":"item.3.item.2"},{"linkId":"Section-10/J2030","prefix":"J2030","text":"Screening for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2"}],"id":"item.3.item.3"},{"linkId":"Section-10/J2040","prefix":"J2040","text":"Treatment for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0"},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2"}],"id":"item.3.item.4"}],"id":"item.3","description":"In Section J of the form, the patient is asked about their health conditions."},{"linkId":"Section-10/J0900","prefix":"J0900","text":"Pain Screening","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3"}],"id":"item.3.item.0","description":"The patient is asked to participate in a pain screening."},{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0","description":"Was the patient or resident screened for pain?"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1","description":"When was the patient first screened for pain?"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2","description":"The severity of the patient's or resident's pain was:"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3","description":"The type of standardized pain tool used for the patient is:"},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Pain Active Problem. Is pain an active problem for the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.1","description":"Is pain an active problem for the patient or resident?"},{"linkId":"Section-10/J0910","prefix":"J0910","text":"Comprehensive Pain Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2"}],"id":"item.3.item.2","description":"The patient is required to fill out a comprehensive pain assessment."},{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0","description":"Was a comprehensive pain assessment conducted on the patient?"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1","description":"When was the date of the patient's comprehensive pain assessment?"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2","description":"The patient's form included a comprehensive pain assessment which stated: \"Check all that apply.\""},{"linkId":"Section-10/J2030","prefix":"J2030","text":"Screening for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2"}],"id":"item.3.item.3","description":"The patient is undergoing screening for shortness of breath."},{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0","description":"Was the patient or resident screened for symptoms of shortness of breath?"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1","description":"What was the date of the patient's first screening for shortness of breath?"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2","description":"Did the screening indicate that the patient had shortness of breath?"},{"linkId":"Section-10/J2040","prefix":"J2040","text":"Treatment for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0"},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2"}],"id":"item.3.item.4","description":"What is the patient's treatment for shortness of breath?"},{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0","description":"Was the treatment for the patient's shortness of breath initiated? Please select the most accurate response."},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1","description":"What is the date when the treatment for shortness of breath was initiated for the patient?"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2","description":"What types of treatment for shortness of breath has the patient initiated? Please check all that apply."},{"linkId":"Section-14","text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/N0500","prefix":"N0500","text":"Scheduled Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1"}],"id":"item.4.item.0"},{"linkId":"Section-14/N0510","prefix":"N0510","text":"PRN Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0"},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1"}],"id":"item.4.item.1"},{"linkId":"Section-14/N0520","prefix":"N0520","text":"Bowel Regimen - Complete only if {scheduled opioid or PRN opioid = yes}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0"},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1"}],"id":"item.4.item.2"}],"id":"item.4","description":"In Section N of the form, the patient is asked to provide information about their medications."},{"linkId":"Section-14/N0500","prefix":"N0500","text":"Scheduled Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1"}],"id":"item.4.item.0","description":"Does the patient have a scheduled opioid medication regimen?"},{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0","description":"Did the patient have a scheduled opioid initiated or continued?"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1","description":"The date the patient's opioid treatment was initiated or continued is scheduled for:"},{"linkId":"Section-14/N0510","prefix":"N0510","text":"PRN Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0"},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1"}],"id":"item.4.item.1","description":"Does the patient take opioid medication as needed?"},{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0","description":"Was a PRN opioid initiated or continued for the patient? The answer choices are: initiated, continued, or neither."},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1","description":"The date on which the patient's PRN opioid was initiated or continued."},{"linkId":"Section-14/N0520","prefix":"N0520","text":"Bowel Regimen - Complete only if {scheduled opioid or PRN opioid = yes}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0"},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1"}],"id":"item.4.item.2","description":"The patient should complete the section \"Bowel Regimen\" only if they are scheduled for opioid treatment or have been prescribed opioids on an as-needed basis."},{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0","description":"Was a bowel regimen initiated or continued for the patient? Please select the most accurate response."},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1","description":"The date when the patient's bowel regimen was initiated or continued is required."},{"linkId":"Section-50","text":"Section O: Service Utilization","type":"group","readOnly":true,"item":[{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.0"}],"id":"item.5","description":"In Section O of the form, the patient's service utilization is assessed."},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.0","description":"What was the level of care the patient received in the final 3 days?"},{"linkId":"Section-48","text":"Section Z: Record Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0"},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1"}],"id":"item.6","description":"In section Z of the form, the administration records pertaining to the patient are documented."},{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0","description":"The signature of the person who completed the patient's assessment is required."},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0","description":"The patient is required to provide their signature, title, and date they completed section A."},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1","description":"The patient needs to provide their Signature, Title, ensure all Sections are filled out, and include the Date the Section was completed B."},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2","description":"The patient needs to provide their signature, title, and complete the sections required on the form. They should also include the date the section was completed, indicated as section C."},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3","description":"The patient filled out the signature, title, and sections, and completed section D on a specific date."},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4","description":"The sections of the form labeled \"Signature\", \"Title\", and \"Date Section Completed E\" should be filled out by the patient."},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5","description":"The form for the patient includes sections for signature, title, and the date when the section was completed."},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6","description":"The patient's signature, title, and the date the section was completed are all required in Section G."},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7","description":"The patient is required to provide their signature and title in the designated sections, and also specify the date when the section was completed."},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8","description":"The patient needs to provide their signature, title, and the sections they have completed on the form, along with the date the section was finished."},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9","description":"The patient is required to provide their signature, title, and date for each completed section on the form."},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10","description":"The patient is required to provide their signature, title, and date on the sections they have completed in Section K."},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11","description":"The patient must provide their signature, title, and date in the sections indicated upon completion."},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1","description":"The signature of the RN Coordinator is required to verify the completion of the patient's assessment."},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0","description":"The form requires the patient's signature."},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1","description":"The date on which the Registered Nurse Assessment Coordinator signed the patient's assessment as complete."},null],"_id":"kzb6LyQDMQiGXhubD"} {"responseType":"QuestionnaireResponse","questionnaire":"HIS-HD-2.00.0","id":"HIS-HD-2.00.0-1","title":"Hospice Item Set - Hospice Discharge Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-09-20T06:33:39.936Z","item":[{"linkId":"Section-36","text":"Section A: Administrative Information","type":"group","readOnly":true,"item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0"},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3"},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5"},{"linkId":"Section-36/A0270","prefix":"A0270","text":"Discharge Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.6"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1"}],"id":"item.0.item.7"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3"}],"id":"item.0.item.8"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1"}],"id":"item.0.item.9"},{"linkId":"Section-36/A2115","prefix":"A2115","text":"Reason for Discharge","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.10"}],"id":"item.0","description":"The section A on the form is for administrative information about the patient."},{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0","description":"The form asks for the patient's Medicaid Number. They should enter \"+\" if their Medicaid application is pending, or \"N\" if they are not a Medicaid recipient."},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1","description":"What is the patient's gender?"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2","description":"What is the patient's birth date?"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3","description":"The type of record pertaining to the patient needs to be identified."},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4","description":"The reason for the patient's assessment should be clearly specified."},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5","description":"What is the patient's admission date?"},{"linkId":"Section-36/A0270","prefix":"A0270","text":"Discharge Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.6","description":"What is the patient's discharge date?"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1"}],"id":"item.0.item.7","description":"The facility has designated provider numbers for the patient."},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0","description":"What is the patient's National Provider Identifier (NPI)?"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1","description":"The patient needs to provide their CMS Certification Number (CCN)."},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3"}],"id":"item.0.item.8","description":"What is the legal name of the patient or resident?"},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0","description":"What is the patient's first name?"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1","description":"What is the patient's middle initial?"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2","description":"What is the patient's last name?"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3","description":"What is the patient's suffix?"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1"}],"id":"item.0.item.9","description":"The patient needs to provide their Social Security and Medicare numbers."},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0","description":"What is the patient's Social Security Number?"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1","description":"What is the patient's Medicare number?"},{"linkId":"Section-36/A2115","prefix":"A2115","text":"Reason for Discharge","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.10","description":"What is the reason for the patient's discharge?"},{"linkId":"Section-47","text":"Section F: Preferences","type":"group","readOnly":true,"item":[{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR preference","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.1.item.0"}],"id":"item.1","description":"In section F of the form, the patient's preferences are to be indicated."},{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR preference","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.1.item.0","description":"What is the patient's preference regarding CPR?"},{"linkId":"Section-9","text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"}],"id":"item.2","description":"In Section I of the form, the active diagnoses of the patient are listed."},{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"The principal diagnosis for the patient is still undetermined."},{"linkId":"Section-10","text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J0100","prefix":"J0100","text":"Pain Management","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.3.item.0"}],"id":"item.3","description":"In Section J of the form, the patient is asked to provide information about their health conditions."},{"linkId":"Section-10/J0100","prefix":"J0100","text":"Pain Management","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.3.item.0","description":"Does the patient require pain management?"},{"linkId":"Section-14","text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/M2003","prefix":"M2003","text":"Medication follow-up","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.4.item.0"}],"id":"item.4","description":"In Section N of the form, it asks about the patient's medications."},{"linkId":"Section-14/M2003","prefix":"M2003","text":"Medication follow-up","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.4.item.0","description":"Does the patient require a medication follow-up?"},{"linkId":"Section-50","text":"Section O: Service Utilization","type":"group","readOnly":true,"item":[{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.0"},{"linkId":"Section-50/O5010","prefix":"O5010","text":"Number of hospice visits in final 3 days. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0"},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1"},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2"}],"id":"item.5.item.1"},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Registered Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.2"},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"Registered Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.3"},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"Registered Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.4"},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.5"},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.6"},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.7"},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"Medical Social Worker - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.8"},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"Medical Social Worker - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.9"},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"Medical Social Worker - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.10"},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Chaplain or Spiritual Counselor - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.11"},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Chaplain or Spiritual Counselor -Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.12"},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Chaplain or Spiritual Counselor - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.13"},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Licensed Professional Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.14"},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Licensed Professional Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.15"},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Licensed Professional Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.16"},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Aide - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.17"},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Aide - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.18"},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Aide - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.19"},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Level of care in final 7 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.20"},{"linkId":"Section-50/O5030","prefix":"O5030","text":"Number of hospice visits in 3 to 6 days prior to death. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3"}],"id":"item.5.item.21"},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"Registered Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.22"},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"Registered Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.23"},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"Registered Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.24"},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"Registered Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.25"},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.26"},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.27"},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.28"},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.29"},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Medical Social Worker - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.30"},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"Medical Social Worker - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.31"},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"Medical Social Worker - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.32"},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"Medical Social Worker - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.33"},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Chaplain or Spiritual Counselor - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.34"},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"Chaplain or Spiritual Counselor - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.35"},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"Chaplain or Spiritual Counselor - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.36"},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Chaplain or Spiritual Counselor - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.37"},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"Licensed Professional Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.38"},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"Licensed Professional Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.39"},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Licensed Professional Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.40"},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"Licensed Professional Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.41"},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Aide - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.42"},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"Aide - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.43"},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Aide - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.44"},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Aide - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.45"}],"id":"item.5","description":"In section O of the form, the patient's service utilization is assessed."},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.0","description":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final three days of their life?"},{"linkId":"Section-50/O5010","prefix":"O5010","text":"Number of hospice visits in final 3 days. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0"},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1"},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2"}],"id":"item.5.item.1","description":"The form requires the patient to enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated, specifically focusing on the final three days of hospice care."},{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0","description":"The number of hospice visits the patient had on the day of their death."},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1","description":"The form asked the patient how many hospice visits they had one day prior to their death."},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2","description":"How many hospice visits did the patient have two days prior to death?"},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Registered Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.2","description":"Did the registered nurse visit the patient on the day of death?"},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"Registered Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.3","description":"The registered nurse visited the patient one day prior to their death."},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"Registered Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.4","description":"Did the registered nurse visit the patient two days prior to their death?"},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.5","description":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant on the day of their death?"},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.6","description":"Did the patient have a visit from a physician, nurse practitioner, or physician assistant one day prior to their death?"},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.7","description":"Did the patient visit a physician, nurse practitioner, or physician assistant two days prior to their death?"},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"Medical Social Worker - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.8","description":"Did the medical social worker visit the patient on the day of their death?"},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"Medical Social Worker - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.9","description":"The medical social worker visited the patient one day prior to their death."},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"Medical Social Worker - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.10","description":"The medical social worker visited the patient two days prior to their death."},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Chaplain or Spiritual Counselor - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.11","description":"Did the patient receive a visit from a Chaplain or Spiritual Counselor on the day of their death?"},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Chaplain or Spiritual Counselor -Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.12","description":"Did the patient receive a visit from a chaplain or spiritual counselor one day prior to their death?"},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Chaplain or Spiritual Counselor - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.13","description":"Did the patient receive a visit from a chaplain or spiritual counselor two days prior to death?"},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Licensed Professional Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.14","description":"Did the Licensed Professional Nurse visit the patient on the day of their death?"},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Licensed Professional Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.15","description":"Did the licensed professional nurse visit the patient one day prior to their death?"},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Licensed Professional Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.16","description":"The patient was visited by a Licensed Professional Nurse two days prior to their death."},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Aide - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.17","description":"Did the aide visit the patient on the day of death?"},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Aide - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.18","description":"Did the aide visit the patient one day prior to their death?"},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Aide - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.19","description":"Did the patient receive an aide visit two days prior to death?"},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Level of care in final 7 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.20","description":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final seven days of their life?"},{"linkId":"Section-50/O5030","prefix":"O5030","text":"Number of hospice visits in 3 to 6 days prior to death. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3"}],"id":"item.5.item.21","description":"The form is asking for the number of visits the patient received from hospice staff in the 3 to 6 days prior to their death. The respondent should enter the number of visits provided by hospice staff from the indicated discipline, on each of the specified dates."},{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0","description":"How many hospice visits did the patient have three days prior to death?"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1","description":"How many hospice visits did the patient have four days prior to death in the period of 3 to 6 days before death?"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2","description":"How many hospice visits did the patient have five days prior to death?"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3","description":"How many hospice visits did the patient have in the six days prior to their death?"},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"Registered Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.22","description":"The patient was visited by a registered nurse three days prior to their death."},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"Registered Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.23","description":"The registered nurse visited the patient four days prior to their death."},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"Registered Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.24","description":"The registered nurse visited the patient five days prior to their death."},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"Registered Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.25","description":"The registered nurse visited the patient six days prior to their death."},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.26","description":"Did the patient visit a physician, nurse practitioner, or physician assistant three days prior to death?"},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.27","description":"The patient visited the physician, nurse practitioner, or physician assistant four days prior to their death."},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.28","description":"Did the patient visit a physician, nurse practitioner, or physician assistant five days prior to their death?"},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.29","description":"The patient was visited by a physician, nurse practitioner, or physician assistant six days prior to death."},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Medical Social Worker - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.30","description":"The medical social worker visited the patient three days prior to their death."},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"Medical Social Worker - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.31","description":"The medical social worker visited the patient four days prior to their death."},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"Medical Social Worker - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.32","description":"The medical social worker visited the patient five days prior to their death."},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"Medical Social Worker - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.33","description":"The medical social worker visited the patient six days prior to their death."},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Chaplain or Spiritual Counselor - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.34","description":"Did the patient receive a visit from a chaplain or spiritual counselor three days prior to death?"},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"Chaplain or Spiritual Counselor - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.35","description":"Did the patient receive a visit from a chaplain or spiritual counselor four days prior to death?"},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"Chaplain or Spiritual Counselor - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.36","description":"Did the patient receive visits from a chaplain or spiritual counselor five days prior to death?"},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Chaplain or Spiritual Counselor - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.37","description":"Did the patient receive a visit from a chaplain or spiritual counselor six days prior to death?"},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"Licensed Professional Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.38","description":"The licensed professional nurse visited the patient three days prior to their death."},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"Licensed Professional Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.39","description":"The Licensed Professional Nurse visited the patient four days prior to their death."},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Licensed Professional Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.40","description":"The patient was visited by a licensed professional nurse five days prior to their death."},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"Licensed Professional Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.41","description":"The Licensed Professional Nurse visited the patient six days prior to their death."},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Aide - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.42","description":"The patient had visits from an aide three days prior to their death."},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"Aide - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.43","description":"Did the aide visit the patient four days prior to death?"},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Aide - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.44","description":"Did the patient receive aid visits five days prior to death?"},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Aide - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.45","description":"Did the aide visit the patient six days prior to death?"},{"linkId":"Section-48","text":"Section Z: Record Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0"},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1"}],"id":"item.6","description":"In Section Z, the record administration pertaining to the patient needs to be filled out."},{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0","description":"The signature of the person who completed the patient's assessment is required."},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0","description":"The patient needs to provide their signature, title, and the date on which they completed section A."},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1","description":"The patient is required to provide their signature and title, and then complete section B, after which they must record the date the section was completed."},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2","description":"The patient should provide their signature, title, and date in the section marked 'C'."},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3","description":"The patient was required to provide their signature and title, fill out several sections, and note down the date they completed section D."},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4","description":"\"The patient is required to provide a signature, title, and complete various sections. They also need to provide the date on which the section E was completed.\""},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5","description":"The patient completed the sections of the form and signed it, indicating their title and date when they finished section F."},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6","description":"The patient needs to provide their signature, title, and the date the sections were completed in Section G."},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7","description":"The patient needs to provide their signature, title, and the date on which the form section H was completed."},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8","description":"The patient is required to provide their signature, title, the sections they have completed, and the date on which the section was completed."},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9","description":"The patient's form includes their signature, title, date, and the sections they completed, specifically section J."},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10","description":"The patient is required to provide their signature, title, and the date on which the sections were completed."},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11","description":"The form for the patient includes sections for a signature, title, and the date when the section was completed."},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1","description":"The signature of the RN Coordinator is required to verify the completion of the patient's assessment."},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0","description":"The form requires the patient's signature."},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1","description":"The date when the Registered Nurse Assessment Coordinator signed the patient's assessment as complete."},null],"_id":"DSHtgtAuTiBwcFwqk"} {"responseType":"QuestionnaireResponse","questionnaire":"IRF-PAI-IA-3.0","id":"IRF-PAI-IA-3.0-1","title":"Inpatient Rehabilitation Facility Patient Assessment Instrument - IRF Admission","description":"Assessment data collected on all Medicare Part A fee-for-service patients who receive services under Part A from an inpatient rehabilitation facility (IRF) at admission and upon discharge.","status":"draft","authored":"2024-09-20T06:34:32.500Z","item":[{"linkId":"Section-45","text":"Discharge Information","type":"group","readOnly":true,"item":[{"linkId":"Section-45/40","prefix":"40","text":"Discharge date","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.0"}],"id":"item.0","description":"The patient's discharge information is ready to be reviewed."},{"linkId":"Section-45/40","prefix":"40","text":"Discharge date","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.0","description":"What is the patient's discharge date?"},{"linkId":"Section-38","code":[{"system":"http://loinc.org","code":"85395-2","display":"IRF-PAI v3.0 - Identification information [CMS Assessment]"}],"text":"Identification Information","type":"group","readOnly":true,"item":[{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.0"},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.1"},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.1.item.2"},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.1.item.3"},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.4"},{"linkId":"Section-38/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.1.item.5"},{"linkId":"Section-38/A0800","prefix":"A0800","text":"Gender","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}],"id":"item.1.item.6"},{"linkId":"Section-38/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.7"},{"linkId":"Section-38/A1200","prefix":"A1200","text":"Marital Status","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}],"id":"item.1.item.8"},{"linkId":"Section-38/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.9"},{"linkId":"Section-38/11","prefix":"11","text":"Zip Code of {Patient's/Resident's} Pre-Hospital Residence","type":"text","repeats":false,"readOnly":false,"maxLength":5,"id":"item.1.item.10"},{"linkId":"Section-38/13","prefix":"13","text":"Assessment Reference Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.11"},{"linkId":"Section-38/14","prefix":"14","text":"Admission Class","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27331-0","display":"Initial rehab"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27332-8","display":"Evaluation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4395-5","display":"Readmission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27335-1","display":"Continuing rehabilitation"}}],"id":"item.1.item.12"},{"linkId":"Section-38/17","prefix":"17","text":"Pre-hospital Living With (Code only if item {Pre-hospital Living Setting} is Home)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27350-0","display":"Alone"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27351-8","display":"Family/Relatives"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27352-6","display":"Friends"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27353-4","display":"Attendant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}],"id":"item.1.item.13"},{"linkId":"Section-38/15A","prefix":"15A","text":"Admit From","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.14"},{"linkId":"Section-38/16A","prefix":"16A","text":"Pre-hospital Living Setting. Use codes from {Admit From}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.15"},{"linkId":"Section-38/1","prefix":"1","text":"{Facility/Provider} Information","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0"}],"id":"item.1.item.16"},{"linkId":"Section-38/5B","prefix":"5B","text":"{Patient/Resident} Identification Number","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.17"},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}],"id":"item.1.item.18"}],"id":"item.1","description":"The form requires the patient's identification information."},{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.0","description":"What is the patient's CMS Certification Number (CCN)?"},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.1","description":"What is the patient's first name?"},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.1.item.2","description":"What is the patient's last name?"},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.1.item.3","description":"What is the patient's Social Security Number?"},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.4","description":"What is the patient's Medicare number?"},{"linkId":"Section-38/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.1.item.5","description":"The patient should enter a \"+\" in the section labeled \"Medicaid Number\" if their Medicaid application is pending, or a \"N\" if they are not a Medicaid recipient."},{"linkId":"Section-38/A0800","prefix":"A0800","text":"Gender","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}],"id":"item.1.item.6","description":"What is the patient's gender? The options are male, female, or other."},{"linkId":"Section-38/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.7","description":"What is the patient's birth date?"},{"linkId":"Section-38/A1200","prefix":"A1200","text":"Marital Status","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}],"id":"item.1.item.8","description":"What is the patient's marital status? Is they married, single, divorced, or widowed?"},{"linkId":"Section-38/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.9","description":"The admission date of the patient is when they were admitted to the hospital."},{"linkId":"Section-38/11","prefix":"11","text":"Zip Code of {Patient's/Resident's} Pre-Hospital Residence","type":"text","repeats":false,"readOnly":false,"maxLength":5,"id":"item.1.item.10","description":"What is the zip code of the patient's pre-hospital residence?"},{"linkId":"Section-38/13","prefix":"13","text":"Assessment Reference Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.11","description":"The assessment reference date for the patient has been set."},{"linkId":"Section-38/14","prefix":"14","text":"Admission Class","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27331-0","display":"Initial rehab"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27332-8","display":"Evaluation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4395-5","display":"Readmission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27335-1","display":"Continuing rehabilitation"}}],"id":"item.1.item.12","description":"The admission class for the patient is being determined."},{"linkId":"Section-38/17","prefix":"17","text":"Pre-hospital Living With (Code only if item {Pre-hospital Living Setting} is Home)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Alone"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27350-0","display":"Alone"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Family / Relatives"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27351-8","display":"Family/Relatives"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Friends"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27352-6","display":"Friends"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Attendant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27353-4","display":"Attendant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Other"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}],"id":"item.1.item.13","description":"The patient's pre-hospital living situation should be coded only if the patient was living at home before hospitalization."},{"linkId":"Section-38/15A","prefix":"15A","text":"Admit From","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.14","description":"From where was the patient admitted?"},{"linkId":"Section-38/16A","prefix":"16A","text":"Pre-hospital Living Setting. Use codes from {Admit From}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.15","description":"The pre-hospital living setting of the patient is determined by using codes from the 'Admit From' category."},{"linkId":"Section-38/1","prefix":"1","text":"{Facility/Provider} Information","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0"}],"id":"item.1.item.16","description":"The form contains a section for the patient to provide information about the facility or provider they are connected with.\n"},{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0","description":"What is the name of the facility or provider for the patient?"},{"linkId":"Section-38/5B","prefix":"5B","text":"{Patient/Resident} Identification Number","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.17","description":"What is the patient's or resident's identification number?"},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}],"id":"item.1.item.18","description":"The patient should check all the boxes that apply to their race or ethnicity."},{"linkId":"Section-41","code":[{"system":"http://loinc.org","code":"87415-6","display":"IRF-PAI v3.0 - Medical Info [CMS Assessment]"}],"text":"Medical Information","type":"group","readOnly":true,"item":[{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Height (in inches). Record most recent height measure since {admission}","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"Weight (in pounds). Base weight on most recent measure in last {specify time period in days}; measure weight consistently, according to standard {facility/setting} practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer","repeats":false,"readOnly":false,"maxLength":3,"id":"item.2.item.1"},{"linkId":"Section-41/21A","prefix":"21A","text":"Impairment Group - Admission: Condition requiring admission to rehabilitation; code according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.2.item.2"},{"linkId":"Section-41/23","prefix":"23","text":"Date of Onset of Impairment","type":"open-choice","repeats":false,"readOnly":false,"id":"item.2.item.3"},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Are there any arthritis conditions recorded in items {impairment group, etiologic diagnosis, or comorbid conditions} that meet all the regulatory requirements for {IRF} classification","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.2.item.4"},{"linkId":"Section-41/22","prefix":"22","text":"Etiologic Diagnosis: (Use ICD codes to indicate the etiologic problem that led to the condition for which the {patient/resident} is receiving rehabilitation)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0"},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1"},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2"}],"id":"item.2.item.5"},{"linkId":"Section-41/24","prefix":"24","text":"Comorbid Conditions. Use ICD codes to enter comorbid medical conditions","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8"},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18"},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21"},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24"}],"id":"item.2.item.6"},{"linkId":"Section-41/21","prefix":"21","text":"Impairment group","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0"}],"id":"item.2.item.7"}],"id":"item.2","description":"The form is requesting the patient's medical information."},{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Height (in inches). Record most recent height measure since {admission}","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"The form asks for the patient's height in inches and requests the most recent measurement since their admission."},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"Weight (in pounds). Base weight on most recent measure in last {specify time period in days}; measure weight consistently, according to standard {facility/setting} practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer","repeats":false,"readOnly":false,"maxLength":3,"id":"item.2.item.1","description":"The patient's weight, in pounds, should be based on the most recent measurement taken within the specified time period in days. It's important to measure the patient's weight consistently, adhering to the standard practice of the facility or setting. For instance, this could be done in the morning after voiding, before a meal, with shoes off, and so on."},{"linkId":"Section-41/21A","prefix":"21A","text":"Impairment Group - Admission: Condition requiring admission to rehabilitation; code according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.2.item.2","description":"The impairment group on the admission form refers to the condition that required the patient's admission to rehabilitation, which should be coded according to Appendix A."},{"linkId":"Section-41/23","prefix":"23","text":"Date of Onset of Impairment","type":"open-choice","repeats":false,"readOnly":false,"id":"item.2.item.3","description":"When did the patient's impairment begin?"},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Are there any arthritis conditions recorded in items {impairment group, etiologic diagnosis, or comorbid conditions} that meet all the regulatory requirements for {IRF} classification","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.2.item.4","description":"Does the patient have any arthritis conditions recorded in the impairment group, etiologic diagnosis, or comorbid conditions that meet all the regulatory requirements for Inpatient Rehabilitation Facility (IRF) classification?"},{"linkId":"Section-41/22","prefix":"22","text":"Etiologic Diagnosis: (Use ICD codes to indicate the etiologic problem that led to the condition for which the {patient/resident} is receiving rehabilitation)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0"},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1"},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2"}],"id":"item.2.item.5","description":"The etiologic diagnosis requires the use of ICD codes to indicate the underlying problem that led to the condition for which the patient is receiving rehabilitation."},{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0","description":"The form for the patient includes a section labeled \"Etiologic Diagnosis A\"."},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1","description":"The form for the patient includes a section labeled \"Etiologic Diagnosis B\"."},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2","description":"The form asks for the patient's etiologic diagnosis C."},{"linkId":"Section-41/24","prefix":"24","text":"Comorbid Conditions. Use ICD codes to enter comorbid medical conditions","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8"},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18"},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21"},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24"}],"id":"item.2.item.6","description":"The patient is instructed to use ICD codes to enter their comorbid medical conditions under the section labeled \"Comorbid Conditions.\""},{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0","description":"Does the patient have a comorbid condition A?"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1","description":"Does the patient have Comorbid Condition B?"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2","description":"Does the patient have Comorbid Condition C?"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3","description":"Does the patient have any comorbid condition D?"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4","description":"Does the patient have a comorbid condition E?"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5","description":"Does the patient have a comorbid condition F?"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6","description":"Does the patient have comorbid condition G?"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7","description":"Does the patient have a comorbid condition H?"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8","description":"Does the patient have a comorbid condition? If yes, please specify."},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9","description":"Does the patient have Comorbid Condition J?"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10","description":"Does the patient have a comorbid condition K?"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11","description":"Does the patient have any comorbid condition L?"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12","description":"Does the patient have a comorbid condition M?"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13","description":"Does the patient have a comorbid condition N?"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14","description":"Does the patient have any comorbid conditions?"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15","description":"Does the patient have a comorbid condition P?"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16","description":"Does the patient have a comorbid condition?"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17","description":"Does the patient have a comorbid condition R?"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18","description":"The form asks if the patient has any comorbid conditions."},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19","description":"Does the patient have a comorbid condition T?"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20","description":"Does the patient have a comorbid condition U?"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21","description":"Does the patient have a comorbid condition V? Please indicate yes or no."},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22","description":"Does the patient have any comorbid condition W?"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23","description":"Does the patient have a comorbid condition X?"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24","description":"Does the patient have comorbid condition Y?"},{"linkId":"Section-41/21","prefix":"21","text":"Impairment group","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0"}],"id":"item.2.item.7","description":"What is the patient's impairment group?"},{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0","description":"What is the impairment group upon admission for the patient?"},{"linkId":"Section-40","code":[{"system":"http://loinc.org","code":"85401-8","display":"IRF-PAI - Payer information [CMS Assessment]"}],"text":"Payer Information","type":"group","readOnly":true,"item":[{"linkId":"Section-40/20","prefix":"20","text":"Payment Source","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0"},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1"}],"id":"item.3.item.0"}],"id":"item.3","description":"The form requires the patient's payer information."},{"linkId":"Section-40/20","prefix":"20","text":"Payment Source","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0"},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1"}],"id":"item.3.item.0","description":"The payment source for the patient is being determined."},{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0","description":"The primary source of information regarding the patient's health condition is the patient themselves."},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1","description":"The form for the patient includes a section titled \"Secondary Source.\""},{"linkId":"Section-2","code":[{"system":"http://loinc.org","code":"88522-8","display":"IRF-PAI v2.0 - Hearing, speech, and vision - admission [CMS Assessment]"}],"text":"Section B: Hearing, Speech, and Vision","type":"group","readOnly":true,"item":[{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}],"id":"item.4.item.0"},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}],"id":"item.4.item.1"}],"id":"item.4","description":"In Section B of the form, the patient's hearing, speech, and vision capabilities are assessed."},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}],"id":"item.4.item.0","description":"The patient's expression of ideas and wants, considering both verbal and non-verbal expression and excluding language barriers, should be evaluated. Does the patient often communicate their ideas and desires clearly? The answer could be 'Always', 'Often', 'Sometimes', 'Rarely', or 'Never'."},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}],"id":"item.4.item.1","description":"Does the patient understand both verbal and non-verbal content with the use of a hearing aid or device, if used, while excluding any language barriers?"},{"linkId":"Section-3","code":[{"system":"http://loinc.org","code":"88524-4","display":"IRF-PAI v2.0 - Cognitive patterns - admission [CMS Assessment]"}],"text":"Section C: Cognitive Patterns","type":"group","readOnly":true,"item":[{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all {patients/residents}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.5.item.0"},{"linkId":"Section-3/C0200","prefix":"C0200","text":"Repetition of Three Words - Ask {patient/resident}: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}],"id":"item.5.item.1"},{"linkId":"Section-3/C0500","prefix":"C0500","text":"BIMS Summary Score. Add scores for {Brief Interview for Mental Status questions} and fill in total score (00-15). Enter 99 if the {patient/resident} was unable to complete the interview","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.2"},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the Staff Assessment for Mental Status be Conducted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes ({patient/resident} was unable to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}],"id":"item.5.item.3"},{"linkId":"Section-3/C0300","prefix":"C0300","text":"BIMS: Temporal Orientation (orientation to year, month, and day)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0"},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1"},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2"}],"id":"item.5.item.4"},{"linkId":"Section-3/C0400","prefix":"C0400","text":"Recall. Ask {patient/resident}: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0"},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1"},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2"}],"id":"item.5.item.5"},{"linkId":"Section-3/C0900","prefix":"C0900","text":"Memory/Recall Ability: Check all that the {patient/resident} was normally able to recall","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above were recalled"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}],"id":"item.5.item.6"}],"id":"item.5","description":"In Section C of the form, the patient's cognitive patterns are assessed."},{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all {patients/residents}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.5.item.0","description":"Should a Brief Interview for Mental Status be conducted? It is suggested to attempt to conduct the interview with all patients or residents."},{"linkId":"Section-3/C0200","prefix":"C0200","text":"Repetition of Three Words - Ask {patient/resident}: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}],"id":"item.5.item.1","description":"The form asks the patient, \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" The number of words repeated after the first attempt is then recorded by the medical professional."},{"linkId":"Section-3/C0500","prefix":"C0500","text":"BIMS Summary Score. Add scores for {Brief Interview for Mental Status questions} and fill in total score (00-15). Enter 99 if the {patient/resident} was unable to complete the interview","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.2","description":"The BIMS Summary Score should be calculated by adding the scores for the Brief Interview for Mental Status questions and filling in the total score, which ranges from 00 to 15. If the patient or resident was unable to complete the interview, the score to be entered should be 99."},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the Staff Assessment for Mental Status be Conducted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes ({patient/resident} was unable to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}],"id":"item.5.item.3","description":"Should the staff assessment for the patient's mental status be conducted?"},{"linkId":"Section-3/C0300","prefix":"C0300","text":"BIMS: Temporal Orientation (orientation to year, month, and day)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0"},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1"},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2"}],"id":"item.5.item.4","description":"The patient's BIMS assessment includes a temporal orientation evaluation, which evaluates their orientation to the current year, month, and day."},{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0","description":"The form asks the patient or resident, \"Please tell me what year it is right now.\" They are able to report the correct year."},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1","description":"The form asks the patient or resident, \"What month are we in right now?\" The patient or resident should be able to report the correct month."},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2","description":"Ask the patient or resident: \"What day of the week is today?\" They should be able to report the correct day of the week."},{"linkId":"Section-3/C0400","prefix":"C0400","text":"Recall. Ask {patient/resident}: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0"},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1"},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2"}],"id":"item.5.item.5","description":"The doctor asks the patient, \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If the patient is unable to remember a word, the doctor gives a cue, such as 'something to wear', 'a color', or 'a piece of furniture', for that particular word."},{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0","description":"The patient is able to recall the word \"sock\"."},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1","description":"The patient is able to recall the color \"blue\"."},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2","description":"Is the patient able to recall \"bed\"?"},{"linkId":"Section-3/C0900","prefix":"C0900","text":"Memory/Recall Ability: Check all that the {patient/resident} was normally able to recall","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above were recalled"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}],"id":"item.5.item.6","description":"The patient's or resident's ability to recall normally should be assessed. Please check all that apply."},{"linkId":"Section-37","code":[{"system":"http://loinc.org","code":"88482-5","display":"Functional abilities and goals - admission [CMS Assessment]"}],"text":"Section GG: Functional Abilities and Goals","type":"group","readOnly":true,"item":[{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.0"},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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If managing an ostomy, include wiping the opening but not managing equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.13"},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.14"},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.28"},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the {patient/resident} use a wheelchair and/or scooter? - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.6.item.29"},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.30"},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.31"},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.32"},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.33"},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.34"},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.35"},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.36"},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.37"},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.45"},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.46"},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.47"},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.48"},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"4 steps: The ability to go up and down four steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.49"},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.50"},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.51"},{"linkId":"Section-37/GG0100","prefix":"GG0100","text":"Prior Functioning: Everyday Activities. Indicate the {patient's/resident's} usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0"},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1"},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2"},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3"}],"id":"item.6.item.52"},{"linkId":"Section-37/GG0130","prefix":"GG0130","text":"Self-Care.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0"},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1"}],"id":"item.6.item.53"},{"linkId":"Section-37/GG0170","prefix":"GG0170","text":"Mobility.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0"},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1"}],"id":"item.6.item.54"},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Prior Device Use. Indicate devices and aids used by the {patient/resident} prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.6.item.55"}],"id":"item.6","description":"In Section GG of the form, the patient's functional abilities and goals are documented."},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.0","description":"The question for the patient or resident is about their eating ability. Specifically, can they use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them? This is in reference to their performance upon admission."},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.1","description":"The form asks about the patient's oral hygiene, specifically their ability to use suitable items to clean their teeth. It also inquires if they have dentures and if so, their ability to insert and remove them from the mouth, as well as manage denture soaking and rinsing with the use of equipment. This is relevant to their admission performance."},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.2","description":"The form asks about the patient's ability to maintain perineal hygiene and adjust their clothes before and after voiding or having a bowel movement. If the patient is managing an ostomy, it includes the task of wiping the opening but not managing the equipment. This is pertaining to their performance upon admission."},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.3","description":"The discharge goal for the patient is to have the ability to use suitable utensils in order to bring food and/or liquid to their mouth and to be able to swallow food and/or liquid once the meal is placed before them."},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.4","description":"The form inquires about the patient's oral hygiene: their ability to use suitable items to clean their teeth. It also asks if the patient has dentures and if so, it assesses their ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with the use of equipment. The goal is to prepare the patient for discharge."},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.5","description":"The discharge goal for the patient is related to toileting hygiene, which refers to their ability to maintain perineal hygiene, adjust clothing before and after voiding or having a bowel movement. If they are managing an ostomy, this also includes wiping the opening, but not managing the equipment."},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.6","description":"The form asks about the patient's ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed, as part of their admission performance."},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.7","description":"The form asks about the patient's admission performance regarding their ability to move from sitting on the side of the bed to lying flat on the bed."},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.8","description":"The form is asking about the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. This is in reference to their admission performance."},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.9","description":"The discharge goal for the patient is to acquire the ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed."},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.10","description":"The discharge goal for the patient is to have the ability to move from sitting on the side of the bed to lying flat on the bed."},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.11","description":"The discharge goal for the patient is to have the ability to move from lying on their back to sitting on the side of the bed without any back support."},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.12","description":"The form asks the patient about their ability to come to a standing position from sitting in a chair, a wheelchair, or on the side of the bed, and requests them to rate their admission performance."},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.13","description":"The form is asking about the patient's ability to transfer to and from a bed to a chair or wheelchair. It is inquiring about their admission performance."},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.14","description":"The form asks about the patient's ability to transfer to and from a toilet or commode on their own as it pertains to their performance upon admission."},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.15","description":"The question on the form asks about the patient's admission performance in relation to their ability to walk. Specifically, it inquires whether, once standing, the patient can walk at least 10 feet in a room, corridor, or similar space."},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.16","description":"Once standing, the patient has the ability to walk at least 50 feet and make two turns as part of their admission performance."},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.17","description":"The form inquires about the patient's capability to walk at least 150 feet in a corridor or similar space once they are standing. This is referred to as the \"Admission Performance\" aspect."},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.18","description":"Once the patient is seated in the wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. This is a requirement for admission performance."},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.19","description":"The admission performance form includes a question regarding the patient's ability, once seated in a wheelchair or scooter, to wheel at least 150 feet in a corridor or similar space."},{"linkId":"Section-37/GG0170K3","prefix":"GG0170K3","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Discharge Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.20","description":"The form asks about the patient's ability to walk at least 150 feet in a corridor or similar space once they are standing, with the label of \"Discharge Performance\"."},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.21","description":"The discharge goal for the patient is to develop the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed."},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.22","description":"The form asks about the patient's ability to transfer themselves to and from a bed to a chair or wheelchair. The discharge goal is to evaluate this capability."},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.23","description":"The discharge goal for the patient refers to their ability to independently get on and off a toilet or commode."},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.24","description":"The question on the form is asking about the patient's ability, once standing, to walk at least 10 feet in a room, corridor, or similar space. The goal is that the patient should be able to do this upon discharge."},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.25","description":"The label is asking about the patient's ability, once standing, to walk a minimum of 50 feet and make two turns. The goal is to achieve this by the time of discharge."},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.26","description":"The form asks if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The response options for this question are 'discharge goal'."},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.27","description":"The discharge goal for the patient is to be able to wheel at least 50 feet and make two turns once seated in a wheelchair or scooter."},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.28","description":"The discharge goal for the patient is to gain the ability to wheel at least 150 feet in a corridor or similar space once seated in a wheelchair or scooter."},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the {patient/resident} use a wheelchair and/or scooter? - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.6.item.29","description":"Does the patient or resident use a wheelchair and/or scooter upon admission?"},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.30","description":"The form is asking the patient to indicate the type of wheelchair or scooter they use upon admission."},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.31","description":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission."},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.32","description":"The form asks about the patient's ability to shower or bathe themselves, which includes tasks such as washing, rinsing, and drying themselves, but does not include washing their back and hair, nor transferring in and out of the tub or shower. The question relates to their performance upon admission."},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.33","description":"The admission form inquires about the patient's ability to dress and undress above the waist, including handling fasteners if applicable, in the section labeled \"Upper body dressing.\""},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.34","description":"On the admission performance form, there is a question about the patient's ability to dress and undress below the waist, including handling fasteners. This does not include dealing with footwear."},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.35","description":"Does the patient have the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable? Please evaluate their performance upon admission."},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.36","description":"On the admission form, it asks about the patient's ability to transfer in and out of a car or van on the passenger side, without including the ability to open or close the door or fasten the seat belt."},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.37","description":"The form asks if the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, either indoors or outdoors. This is in reference to their admission performance."},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.38","description":"The form asks about the patient's ability to go up and down a curb and/or up and down one step in regards to their admission performance."},{"linkId":"Section-37/GG0170N1","prefix":"GG0170N1","text":"4 steps: The ability to go up and down four steps with or without a rail. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.39","description":"The form asks about the patient's ability to go up and down four steps with or without a rail in terms of admission performance."},{"linkId":"Section-37/GG0170O1","prefix":"GG0170O1","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.40","description":"The form asks whether the patient has the ability to go up and down 12 steps with or without a rail as part of their admission performance."},{"linkId":"Section-37/GG0170P1","prefix":"GG0170P1","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.41","description":"The form asks about the patient's admission performance in terms of their ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor."},{"linkId":"Section-37/GG0130E2","prefix":"GG0130E2","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.42","description":"The discharge goal for the patient is to be able to shower or bathe themselves. This means the patient should have the ability to wash, rinse, and dry themselves, excluding washing of the back and hair. It does not include transferring in or out of the tub or shower."},{"linkId":"Section-37/GG0130F2","prefix":"GG0130F2","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.43","description":"The discharge goal for the patient is to be able to dress and undress above the waist, which includes handling any fasteners, if applicable, on their own."},{"linkId":"Section-37/GG0130G2","prefix":"GG0130G2","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.44","description":"The discharge goal for the patient is to be able to independently dress and undress their lower body, below the waist, including handling fasteners, but not including footwear."},{"linkId":"Section-37/GG0130H2","prefix":"GG0130H2","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.45","description":"The form asks about the patient's ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable, and what the discharge goal for this ability is."},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.46","description":"The discharge goal for the patient is to have the ability to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten their seat belt."},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.47","description":"The form asks if the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoor or outdoor, with the discharge goal being the endpoint."},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.48","description":"The question on the form asks about the patient's ability to go up and down a curb and/or up and down one step. The label for this section is \"Discharge Goal\"."},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"4 steps: The ability to go up and down four steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.49","description":"The discharge goal for the patient is to have the ability to go up and down four steps with or without a rail."},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.50","description":"The discharge goal for the patient is to develop the ability to go up and down 12 steps with or without the use of a rail."},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.51","description":"The discharge goal for the patient is to have the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor."},{"linkId":"Section-37/GG0100","prefix":"GG0100","text":"Prior Functioning: Everyday Activities. Indicate the {patient's/resident's} usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0"},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1"},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2"},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3"}],"id":"item.6.item.52","description":"Please indicate the patient's usual ability with everyday activities prior to their current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0","description":"Please code the patient's or resident's need for assistance with bathing, dressing, using the toilet, and eating prior to their current illness, exacerbation, or injury for the Self-Care section."},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1","description":"The form requests the code for the patient's or resident's need for assistance with walking from room to room, with or without a device such as a cane, crutch, or walker, prior to the current illness, exacerbation, or injury to determine their level of indoor mobility and ambulation."},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2","description":"The form asks to code the patient's or resident's need for assistance with internal or external stairs, with or without a device such as a cane, crutch, or walker, prior to the current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3","description":"The form asks to code the patient's or resident's need for assistance with planning regular tasks, such as shopping or remembering to take medication, prior to their current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0130","prefix":"GG0130","text":"Self-Care.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0"},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1"}],"id":"item.6.item.53","description":"The patient is capable of self-care."},{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0","description":"For the category of Self-Care, please code the patient's usual performance at the time of admission for each activity using the 6-point scale. If the activity was not attempted at the time of admission, please code the reason."},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1","description":"Please code the patient's or resident's self-care discharge goals using the 6-point scale. The use of codes 07, 09, 10, or 88 is permissible to code the discharge goals."},{"linkId":"Section-37/GG0170","prefix":"GG0170","text":"Mobility.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0"},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1"}],"id":"item.6.item.54","description":"The patient's mobility status is being assessed."},{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0","description":"For the section on mobility, please code the patient's or resident's usual performance at the time of admission for each activity using the 6-point scale. If a certain activity was not attempted at the time of admission, code the reason."},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1","description":"The form instructs the user to code the patient's or resident's discharge goals using the 6-point scale. The use of codes 07, 09, 10, or 88 is permissible to code the discharge goals."},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Prior Device Use. Indicate devices and aids used by the {patient/resident} prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.6.item.55","description":"Please indicate the devices and aids that the patient or resident used prior to their current illness, exacerbation, or injury. Check all that apply."},{"linkId":"Section-8","code":[{"system":"http://loinc.org","code":"83237-8","display":"Bladder and bowel [CMS Assessment]"}],"text":"Section H: Bladder and Bowel","type":"group","readOnly":true,"item":[{"linkId":"Section-8/H0400","prefix":"H0400","text":"Bowel Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}],"id":"item.7.item.0"},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Bladder Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}],"id":"item.7.item.1"}],"id":"item.7","description":"In section H of the form, the patient's bladder and bowel conditions are addressed."},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Bowel Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}],"id":"item.7.item.0","description":"Please select the one category that best describes the bowel continence of the patient or resident."},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Bladder Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}],"id":"item.7.item.1","description":"Please select the one category that best describes the patient's or resident's bladder continence."},{"linkId":"Section-9","code":[{"system":"http://loinc.org","code":"83264-2","display":"IRF-PAI - Active diagnoses [CMS Assessment]"}],"text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0000","prefix":"I0000","text":"Active Diagnoses in the last 7 days: Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.8.item.0"}],"id":"item.8","description":"In Section I of the form, the patient's active diagnoses are listed."},{"linkId":"Section-9/I0000","prefix":"I0000","text":"Active Diagnoses in the last 7 days: Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.8.item.0","description":"The patient has been asked to indicate all of their active diagnoses from the last 7 days on the form. They should check all that apply. The diagnoses provided in parentheses are just examples and should not be considered as an all-inclusive list."},{"linkId":"Section-10","code":[{"system":"http://loinc.org","code":"83273-3","display":"IRF-PAI - Health conditions - admission [CMS Assessment]"}],"text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J1750","prefix":"J1750","text":"History of Falls: Has the {patient/resident} had two or more falls in the past year or any fall with injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.0"},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Prior Surgery. Did the {patient/resident} have major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.1"}],"id":"item.9","description":"In Section J of the form, the patient's health conditions are being evaluated."},{"linkId":"Section-10/J1750","prefix":"J1750","text":"History of Falls: Has the {patient/resident} had two or more falls in the past year or any fall with injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.0","description":"Does the patient or resident have a history of having two or more falls in the past year, or any fall that resulted in injury in the past year?"},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Prior Surgery. Did the {patient/resident} have major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.1","description":"Did the patient or resident have any major surgery during the 100 days prior to their admission?"},{"linkId":"Section-11","code":[{"system":"http://loinc.org","code":"83244-4","display":"IRF-PAI v2.0 - Swallowing/nutritional status - admission [CMS Assessment]"}],"text":"Section K: Swallowing/Nutritional Status","type":"group","readOnly":true,"item":[{"linkId":"Section-11/K0110","prefix":"K0110","text":"Swallowing/Nutritional Status. Indicate the {patient's/resident's} usual ability to swallow: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Regular food - Solids and liquids swallowed safely without supervision or modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Modified food consistency/supervision - {Patient/Resident} requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Tube/parenteral feeding - Tube/parenteral feeding used wholly or partially as a means of sustenance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}],"id":"item.10.item.0"}],"id":"item.10","description":"In Section K of the form, the patient's swallowing and nutritional status is assessed."},{"linkId":"Section-11/K0110","prefix":"K0110","text":"Swallowing/Nutritional Status. Indicate the {patient's/resident's} usual ability to swallow: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Regular food - Solids and liquids swallowed safely without supervision or modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Modified food consistency/supervision - {Patient/Resident} requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Tube/parenteral feeding - Tube/parenteral feeding used wholly or partially as a means of sustenance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}],"id":"item.10.item.0","description":"Please indicate the patient's usual ability to swallow regarding their swallowing or nutritional status. Check all that apply."},{"linkId":"Section-13","code":[{"system":"http://loinc.org","code":"85055-2","display":"IRF-PAI v3.0, LCDS v4.00 - Skin conditions - admission [CMS Assessment]"}],"text":"Section M: Skin Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-13/M0210","prefix":"M0210","text":"Unhealed Pressure Ulcers/Injuries. Does this {patient/resident} have one or more unhealed pressure ulcers/injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.11.item.0"},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"Number of Stage 2 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.1"},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"Number of Stage 3 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.2"},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"Number of Stage 4 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.3"},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.4"},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.5"},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.6"},{"linkId":"Section-13/M0300","prefix":"M0300","text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0"},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1"},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2"},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3"},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4"},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5"},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6"}],"id":"item.11.item.7"},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"Number of Stage 1 pressure injuries","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.8"}],"id":"item.11","description":"In Section M of the form, the patient's skin conditions are addressed."},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Unhealed Pressure Ulcers/Injuries. Does this {patient/resident} have one or more unhealed pressure ulcers/injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.11.item.0","description":"Does this patient or resident have one or more unhealed pressure ulcers or injuries?"},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"Number of Stage 2 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.1","description":"The patient has how many Stage 2 pressure ulcers?"},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"Number of Stage 3 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.2","description":"How many stage 3 pressure ulcers does the patient have?"},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"Number of Stage 4 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.3","description":"The patient has a certain number of Stage 4 pressure ulcers."},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.4","description":"How many unstageable pressure ulcers/injuries does the patient have due to a non-removable dressing/device?"},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.5","description":"How many unstageable pressure ulcers does the patient have due to coverage of the wound bed by slough and/or eschar?"},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.6","description":"The patient has a certain number of unstageable pressure injuries that present as deep tissue injury."},{"linkId":"Section-13/M0300","prefix":"M0300","text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0"},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1"},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2"},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3"},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4"},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5"},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6"}],"id":"item.11.item.7","description":"The form is asking for the current number of unhealed pressure ulcers/injuries at each stage that the patient has."},{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0","description":"The patient's condition is at Stage 1, where there is intact skin with non-blanchable redness of a localized area, usually over a bony prominence. It is noted that darkly pigmented skin may not exhibit visible blanching. In such cases, dark skin tones may only appear with persistent blue or purple hues."},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1","description":"The patient is at stage 2, which indicates a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. This may also present as an intact or open/ruptured blister."},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2","description":"The patient is at stage 3, which indicates full thickness tissue loss. At this stage, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but it does not obscure the depth of tissue loss. This stage may also include undermining and tunneling."},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3","description":"The patient has stage 4 skin integrity, characterized by full thickness tissue loss with exposed bone, tendon, or muscle. There may be slough or eschar present on some parts of the wound bed, and the condition often includes undermining and tunneling."},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4","description":"The patient has an unstageable condition due to a non-removable dressing or device, although the exact stage is known but cannot be identified because of the non-removable dressing or device."},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5","description":"The patient has a known, but unstageable wound due to the coverage of the wound bed by slough and/or eschar."},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6","description":"The patient has an unstageable deep tissue injury."},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"Number of Stage 1 pressure injuries","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.8","description":"How many Stage 1 pressure injuries does the patient have?"},{"linkId":"Section-14","code":[{"system":"http://loinc.org","code":"88872-7","display":"IRF-PAI v2.0 - Medications - admission [CMS Assessment]"}],"text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/N2001","prefix":"N2001","text":"Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}],"id":"item.12.item.0"},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Medication Follow-up. Did the {facility/setting} contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.12.item.1"}],"id":"item.12","description":"In Section N of the form, the medications that the patient is currently taking are listed."},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}],"id":"item.12.item.0","description":"Did a complete drug regimen review identify any potential clinically significant medication issues for the patient? The options are 'Yes', 'No', and 'Not applicable'."},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Medication Follow-up. Did the {facility/setting} contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.12.item.1","description":"Did the facility or setting in question contact a physician or a physician's designee by midnight of the following calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues related to the patient?"},{"linkId":"Section-15","code":[{"system":"http://loinc.org","code":"83261-8","display":"IRF-PAI v3.0 - Special treatments, procedures, and programs - admission [CMS Assessment]"}],"text":"Section O: Special Treatments, Procedures, and Programs","type":"group","readOnly":true,"item":[{"linkId":"Section-15/O0100","prefix":"O0100","text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that were performed","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}],"id":"item.13.item.0"}],"id":"item.13","description":"In Section O of the form, the patient is asked about special treatments, procedures, and programs they may have undergone."},{"linkId":"Section-15/O0100","prefix":"O0100","text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that were performed","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}],"id":"item.13.item.0","description":"Please indicate all of the special treatments, procedures, and programs that were performed on the patient."},{"linkId":"Section-19","text":"Section Z: Assessment Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-19/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0"},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1"},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2"},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3"},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4"},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5"},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6"},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7"},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8"},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9"},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10"},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11"}],"id":"item.14.item.0"}],"id":"item.14","description":"In Section Z of the form, the assessment administration for the patient is carried out."},{"linkId":"Section-19/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0"},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1"},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2"},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3"},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4"},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5"},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6"},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7"},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8"},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9"},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10"},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11"}],"id":"item.14.item.0","description":"The signature of the person who completed the assessment for the patient is required."},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0","description":"The patient filled out the Signature, Title, Sections, and Date Section Completed A on the form."},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1","description":"The patient needs to provide their signature, title, and date for the sections they have completed in Section B."},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2","description":"The patient needs to complete the signature, title, and sections of the form, and indicate the date the section C was completed."},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3","description":"The patient is required to provide their signature, title, and date the sections that have been completed in Section D."},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4","description":"The patient needs to provide their signature, title, and the sections they have completed, along with the date they finished section E."},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5","description":"The patient's form contains a section for the signature, title, and sections, and also records the date the section was completed."},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6","description":"The patient is required to provide their signature, title, fill in the sections, and add the date the section was completed on form G."},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7","description":"The patient's form contains sections for signature, title, and date, which need to be completed. In section H, the form is completed."},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8","description":"The section titled \"Signature, Title, Sections, Date Section Completed I\" requires the patient's signature, their title, and the date on which they completed the section."},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9","description":"The patient completed the signature, title, and sections on the form, and dated it on section J."},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10","description":"The patient is required to provide their signature and title in the specified sections, and the date when they completed the form."},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11","description":"The patient must provide their signature and title, complete all sections, and include the date that they completed the form."},{"linkId":"Section-49","text":"Therapy Information","type":"group","readOnly":true,"item":[{"linkId":"Section-49/O0401","prefix":"O0401","text":"Week 1: total number of minutes provided","type":"text","repeats":false,"readOnly":false,"item":[{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0"}],"id":"item.15.item.0"}],"id":"item.15","description":"The patient's therapy information is required."},{"linkId":"Section-49/O0401","prefix":"O0401","text":"Week 1: total number of minutes provided","type":"text","repeats":false,"readOnly":false,"item":[{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0"}],"id":"item.15.item.0","description":"In the first week, what was the total number of minutes of care provided to the patient?"},{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0","description":"Does the patient require physical therapy?"},null],"_id":"79WykKu2grzauommK"} {"id":"fasi","responseType":"QuestionnaireResponse","status":"draft","authored":"2024-04-27T18:21:32.181Z","item":[{"linkId":"Section-37/GG0175A","prefix":"GG0175A","text":"Does the patient or resident use a manual wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0175F","prefix":"GG0175F","text":"Does the patient or resident use a motorized wheelchair and/or scooter?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0125B1","prefix":"GG0125B1","text":"Does the patient use an assistive device such as a standard folding walker?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170HH","prefix":"GG0170HH","text":"Does the patient or resident have the ability to walk?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No, and walking goal is not indicated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA31067-4","display":"No, and walking goal is not indicated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"No, and walking is indicated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA31068-2","display":"No, and walking goal is indicated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-6/F0900A1","prefix":"F0900A1","text":"Please identify the usual living arrangement of the patient or resident during the past three days.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident} lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30925-4","display":"Person lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident} lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30926-2","display":"Person lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident} lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30927-0","display":"Person lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident} does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30928-8","display":"Person does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident} was in a medical facility."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30929-6","display":"Person was in a medical facility."}}]},{"linkId":"Section-37/GG0125B","prefix":"GG0125B","text":"Does the patient use an assistive device such as a walker?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Z","prefix":"GG0125Z","text":"Does the patient use an assistive device other than the ones previously mentioned?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125A","prefix":"GG0125A","text":"The patient uses an assistive device, specifically a cane or a crutch.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125AA","prefix":"GG0125AA","text":"In the past month, has the patient used, or expressed or demonstrated a need for an assistive device?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}}]},{"linkId":"Section-6/F0910A","prefix":"F0910A","text":"Does the patient or resident have assistance in their home? The options are \"Yes\" or \"No\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170X7","prefix":"GG0170X7","text":"The patient's usual performance indicates their ability to walk across a street before the light turns red.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170E7","prefix":"GG0170E7","text":"The form inquires about the patient's usual performance in terms of their ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170J7","prefix":"GG0170J7","text":"Does the patient have the ability, once standing, to walk at least 50 feet and make two turns as part of their usual performance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920E1","prefix":"F0920E1","text":"Has the patient paid for medical procedures or treatments, such as changing wound dressings or home exercise programs?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920B2","prefix":"F0920B2","text":"Does the patient require mobility assistance, such as help with bed mobility, transfers, ambulating, or wheeling, and is this assistance unpaid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170K7","prefix":"GG0170K7","text":"Once the patient is standing, they should have the ability to walk at least 150 feet in a corridor or similar space. The usual performance is evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170F8","prefix":"GG0170F8","text":"The form inquires about the patient's ability to transfer to and from a toilet or commode, asking whether their performance is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170D7","prefix":"GG0170D7","text":"Does the patient typically have the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920H1","prefix":"F0920H1","text":"Does the individual advocate or facilitate the patient's participation in appropriate medical care, for example, providing transportation to or from appointments? The options for this are either paid or unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170M7","prefix":"GG0170M7","text":"The form asks about the patient's usual performance in the ability to go up and down a curb and/or up and down one step.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170W8","prefix":"GG0170W8","text":"The patient's ability to walk for 15 minutes without stopping or resting, like through a department store or supermarket, is the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170B7","prefix":"GG0170B7","text":"The form asks about the patient's usual ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130F7","prefix":"GG0130F7","text":"The form asks about the patient's usual performance in terms of their ability to dress and undress their upper body, including handling fasteners if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170X8","prefix":"GG0170X8","text":"The form asks the patient about their ability to walk across a street before the light turns red, with the most dependent performance as an answer choice.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170N7","prefix":"GG0170N7","text":"The form is asking about the patient's usual performance in regards to their ability to go up and down four steps, with or without using a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175B8","prefix":"GG0175B8","text":"Once seated in their manual wheelchair, the patient has the ability to wheel at least 50 feet and make two turns, indicating a most dependent performance level.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920F1","prefix":"F0920F1","text":"Does the patient manage their equipment, for example, oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies, and is it paid for?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920D2","prefix":"F0920D2","text":"Does the patient administer their medication themselves (for example, oral, inhaled, or injectable medications) without any paid assistance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0910B2","prefix":"F0910B2","text":"Please indicate the level of both paid and unpaid assistance in the patient's or resident's home during the past month. The level of assistance was unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No assistance received"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12345-7","display":"No assistance received"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Occasional/short-term assistance"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30934-6","display":"Occasional/short term assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Regular night-time"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30935-3","display":"Regular night-time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Regular daytime"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12164-2","display":"Regular daytime"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Around the clock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12163-4","display":"Around the clock"}}]},{"linkId":"Section-37/GG0130H7","prefix":"GG0130H7","text":"The form asks the patient to evaluate their usual performance in putting on and taking off socks, shoes, or other footwear appropriate for safe mobility. This includes handling fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170O8","prefix":"GG0170O8","text":"The form asks the patient to assess their ability to go up and down 12 steps with or without a rail, with the most dependent performance being the possible response.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130G7","prefix":"GG0130G7","text":"The form asks about the patient's usual performance in their ability to dress and undress below the waist, including fasteners, excluding footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170M8","prefix":"GG0170M8","text":"The form asks about the patient's ability to go up and down a curb and/or up and down one step. The patient's performance is most dependent in this activity.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175G8","prefix":"GG0175G8","text":"Once seated in their motorized wheelchair or scooter, the patient has the ability to wheel at least 50 feet and make two turns. However, their performance indicates that they are most dependent on this form of mobility.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920H2","prefix":"F0920H2","text":"Does the person facilitate or advocate for the patient's participation in appropriate medical care, for instance, by transporting them to or from appointments, without any charge?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0910B1","prefix":"F0910B1","text":"Please indicate the level of both paid and unpaid assistance in the patient's or resident's home during the past month. The choices are \"Paid\", \"Unpaid\", or \"Both Paid and Unpaid\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No assistance received"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12345-7","display":"No assistance received"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Occasional/short-term assistance"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30934-6","display":"Occasional/short term assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Regular night-time"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30935-3","display":"Regular night-time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Regular daytime"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12164-2","display":"Regular daytime"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Around the clock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12163-4","display":"Around the clock"}}]},{"linkId":"Section-37/GG0175B7","prefix":"GG0175B7","text":"The form asks about the patient's ability to wheel at least 50 feet and make two turns once seated in a manual wheelchair, assessing their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170I7","prefix":"GG0170I7","text":"The form asks about the patient's usual performance in terms of their ability to walk at least 10 feet once standing, whether it be in a room, corridor, or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170L7","prefix":"GG0170L7","text":"The form asks about the patient's usual performance in the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, both indoors and outdoors.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170U8","prefix":"GG0170U8","text":"The form asks about the patient's ability to walk from one room to another, maneuver around furniture, and navigate other obstacles indoors. The label classifies the patient's performance as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175C8","prefix":"GG0175C8","text":"Once the patient is seated in the wheelchair, they should have the ability to wheel at least 150 feet in a corridor or similar space. The choices for this ability are with a manual wheelchair or indicating the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185F8","prefix":"GG0185F8","text":"The form asks about the patient's ability to answer a telephone call in their customary manner and maintain it for 1 minute or longer. This does not include getting to the phone. The label for the most dependent performance is used.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185K7","prefix":"GG0185K7","text":"The patient's usual performance in simple financial management includes the ability to complete financial transactions such as counting coins, verifying change for a single item transaction, writing a check, online/mobile bill pay, banking, or shopping.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175E7","prefix":"GG0175E7","text":"The form is asking about the patient's ability to wheel across a street using a manual wheelchair before the light turns red. The patient usually performs this task with their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130F8","prefix":"GG0130F8","text":"The form asks about the patient's ability to dress and undress above the waist, including dealing with fasteners if applicable, and the patient's most dependent performance is being evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175H7","prefix":"GG0175H7","text":"Once the patient is seated in the wheelchair or scooter, does he or she have the ability to wheel at least 150 feet in a corridor or similar space? The options are: Motorized Wheelchair/Scooter or Usual Performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170C7","prefix":"GG0170C7","text":"The form asks about the patient's usual performance in the ability to move from lying on their back to sitting on the side of the bed with their feet flat on the floor, and without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130G8","prefix":"GG0130G8","text":"The form asks about the patient's ability to dress and undress below the waist, including handling fasteners, but not including footwear. It indicates that the patient's performance in this area is mostly dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130D8","prefix":"GG0130D8","text":"The form asks about the patient's ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed. The performance level indicated is \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170K8","prefix":"GG0170K8","text":"The form asks if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The performance level is gauged as 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185E8","prefix":"GG0185E8","text":"The patient's performance level in light shopping is at its most dependent. Once at the store, they can locate and select up to five needed goods, take them to the checkout, and complete the purchasing transaction.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170W7","prefix":"GG0170W7","text":"Does the patient have the ability to walk for 15 minutes without stopping or resting, such as through a department store or supermarket, as part of their usual performance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170V7","prefix":"GG0170V7","text":"The form asks whether the patient has the ability to carry something in both hands, such as several dishes, a light laundry basket, or a tray with food, while walking indoors. The category for this question is 'Usual Performance.'","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170D8","prefix":"GG0170D8","text":"The form asks about the patient's ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. The patient's performance is most dependent in this regard.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920A2","prefix":"F0920A2","text":"Does the patient require unpaid assistance with self-care tasks such as bathing, dressing, toileting, or eating/feeding?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185G7","prefix":"GG0185G7","text":"The question on the form asks about the patient's or resident's usual performance in terms of the ability to place a call in their customary manner and maintain it for 1 minute or longer. Note that this does not include the act of getting to the phone.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185J7","prefix":"GG0185J7","text":"The patient's usual performance in medication management of injectable medications assesses their ability to prepare and take all prescribed injectable medications reliably and safely. This includes the administration of the correct dosage at the appropriate times or intervals.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170C8","prefix":"GG0170C8","text":"The form is asking about the patient's ability to move from lying on their back to sitting on the side of the bed with their feet flat on the floor, without any back support. The patient's performance in this task is categorized as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175J7","prefix":"GG0175J7","text":"The form asks the patient about their ability to wheel across a street before the light turns red once they are seated in a wheelchair or scooter. The options for response are 'Motorized Wheelchair/Scooter' and 'Usual Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185D7","prefix":"GG0185D7","text":"The patient's usual performance in the ability to complete heavier periodic housework, such as doing laundry, vacuuming, and cleaning the bathroom, is evaluated to ensure they can maintain a safe home environment and not be at risk for harm within their home.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185A8","prefix":"GG0185A8","text":"The form inquires about the patient's ability to plan and prepare all aspects of a light cold meal, such as a bowl of cereal, sandwich and cold drink. The patient's performance in this area is marked as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175G7","prefix":"GG0175G7","text":"Once the patient is seated in a wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. The options are either using a motorized wheelchair/scooter or executing their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170O7","prefix":"GG0170O7","text":"The patient's usual performance is their ability to go up and down 12 steps with or without a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175D8","prefix":"GG0175D8","text":"The patient's ability to wheel for 15 minutes once seated in a manual wheelchair, without stopping or resting, for example, through a department store or supermarket, is evaluated as the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185H8","prefix":"GG0185H8","text":"The form is asking about the patient's ability to manage their oral medications. This involves the preparation and safely taking all prescribed oral medications, including the administration of the correct dosage at the appropriate times/intervals. The level of performance is marked as \"most dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125F","prefix":"GG0125F","text":"Does the patient use an assistive device such as a mechanical lift?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175D7","prefix":"GG0175D7","text":"The form asks if the patient has the ability to wheel without stopping or resting for 15 minutes once seated in a manual wheelchair, such as when navigating through a department store or supermarket. The question is about their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170G8","prefix":"GG0170G8","text":"The form asks about the patient's ability to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten the seat belt. The patient's performance in this area is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170I8","prefix":"GG0170I8","text":"The form asks about the patient's ability to walk at least 10 feet once they are standing, whether it be in a room, corridor, or a similar space. The patient's performance is rated as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0180B","prefix":"GG0180B","text":"Please ask the patient to describe at least one or two personal priorities in the area of mobility for the next six months. If the patient does not express any personal priorities in this area, please note this below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0130A7","prefix":"GG0130A7","text":"The form is asking about the patient's usual performance in eating. It refers to their ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185G8","prefix":"GG0185G8","text":"The form asks about the patient's or resident's ability to place a call in their customary manner and maintain it for 1 minute or longer. It does not include getting to the phone. The patient's performance in this area is classified as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175E8","prefix":"GG0175E8","text":"The form asks about the patient's ability to wheel across a street once seated in a wheelchair before the light turns red. The options are from most dependent to a manual wheelchair performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185B7","prefix":"GG0185B7","text":"The form asks whether the patient has the ability to plan and prepare all aspects of a light hot meal, such as heating a bowl of soup and reheating a prepared meal. The label for this question is referring to the patient's usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125L","prefix":"GG0125L","text":"Does the patient use an assistive device such as grab bars?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0905B","prefix":"F0905B","text":"Please ask the patient to describe at least one or two personal priorities in the area of living arrangements for the next six months. If the patient does not express any personal priorities in this area, kindly note this down.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170U7","prefix":"GG0170U7","text":"The form asks about the patient's usual performance in their ability to walk indoors, specifically from room to room, and around furniture and other obstacles.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185E7","prefix":"GG0185E7","text":"The form asks about the patient's usual performance in light shopping tasks. Specifically, it asks if the patient can once at the store locate and select up to five needed goods, take them to the checkout, and complete the purchasing transaction.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170P8","prefix":"GG0170P8","text":"The form inquires about the patient's ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor. The performance level selected for the patient is \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185B8","prefix":"GG0185B8","text":"The form asks about the patient's ability to plan and prepare all aspects of a light hot meal, such as heating a bowl of soup and reheating a prepared meal. It is noted that the patient's performance in this area is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125Q","prefix":"GG0125Q","text":"Does the patient use an assistive device such as a hearing aid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125ZZ","prefix":"GG0125ZZ","text":"The patient has indicated all the assistive devices they needed.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-37/GG0170N8","prefix":"GG0170N8","text":"The form inquires about the patient's ability to go up and down four steps, with or without the assistance of a rail. The performance level was noted as \"most dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0900A2","prefix":"F0900A2","text":"Please identify the patient's or resident's usual living arrangement during the past month.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident} lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30925-4","display":"Person lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident} lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30926-2","display":"Person lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident} lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30927-0","display":"Person lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident} does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30928-8","display":"Person does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident} was in a medical facility."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30929-6","display":"Person was in a medical facility."}}]},{"linkId":"Section-37/GG0170J8","prefix":"GG0170J8","text":"Once the patient is standing, they will be assessed on their ability to walk at least 50 feet and make two turns. The potential ratings for performance in this task range from 'Most Dependent' to 'Independent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130EE7","prefix":"GG0130EE7","text":"The form inquires about the patient's usual performance regarding the ability to shower or bathe themselves, including tasks such as washing, rinsing, and drying themselves. It should be noted that this does not include the act of transferring in or out of the tub or shower.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185C7","prefix":"GG0185C7","text":"The form is asking about the patient's usual performance in terms of their ability to complete light daily housework. This entails maintaining a safe home environment so that the patient is not at risk from harm within their home. Examples of such housework include tasks like wiping counter tops or doing dishes.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130EE8","prefix":"GG0130EE8","text":"The form is asking about the patient's level of ability to bathe themselves, including washing, rinsing, and drying. The question does not include the process of transferring in and out of a tub or shower. The performance level designated is \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920A1","prefix":"F0920A1","text":"Does the patient require paid assistance for self-care activities such as bathing, dressing, toileting, or eating/feeding?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170E8","prefix":"GG0170E8","text":"The form asks about the patient's ability to transfer from a bed to a chair or wheelchair. It is labeled \"Most Dependent Performance\", indicating the need for assistance with this task.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125M","prefix":"GG0125M","text":"Does the patient use an assistive device such as a transfer board?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0130B8","prefix":"GG0130B8","text":"The form asks about the patient's ability to maintain oral hygiene by using suitable items to clean their teeth and, if applicable, their ability to insert and remove dentures into and from their mouth, as well as manage denture soaking and rinsing with the use of equipment. The response category for their performance is \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125S","prefix":"GG0125S","text":"The patient uses an assistive device, specifically stair rails.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0135B","prefix":"GG0135B","text":"Please ask the patient to describe at least one or two personal priorities in the area of self-care for the next six months. If the patient does not express any personal priorities in this area, please record this information below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170P7","prefix":"GG0170P7","text":"The form asks about the patient's usual performance in the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175C7","prefix":"GG0175C7","text":"Once the patient is seated in their manual wheelchair, their usual performance indicates their ability to wheel at least 150 feet in a corridor or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920E2","prefix":"F0920E2","text":"The patient has undergone medical procedures/treatments such as changing a wound dressing or a home exercise program, for which they have not paid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185K8","prefix":"GG0185K8","text":"The form asks about the patient's simple financial management skills, such as their ability to complete financial transactions, counting coins, verifying change for a single item transaction, writing a check, using online/mobile bill pay, banking, or shopping. The patient's performance is most dependent in these areas.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125C","prefix":"GG0125C","text":"Does the patient use an assistive device such as a wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185H7","prefix":"GG0185H7","text":"The patient's usual performance in medication management, specifically for oral medications, refers to their ability to prepare and take all prescribed oral medications reliably and safely. This includes administering the correct dosage at the appropriate times or intervals.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125P","prefix":"GG0125P","text":"Does the patient use an assistive device such as glasses or contact lenses?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175I7","prefix":"GG0175I7","text":"The form asks about the patient's ability to wheel for 15 minutes without stopping or resting, such as through a department store or supermarket, while seated in a wheelchair or scooter. Does the patient typically use a motorized wheelchair or scooter for this task?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125W","prefix":"GG0125W","text":"Does the patient use an assistive device such as a glucometer?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125T","prefix":"GG0125T","text":"Does the patient use an assistive device such as a lift chair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125D","prefix":"GG0125D","text":"Does the patient use an assistive device such as a limb prosthesis?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185J8","prefix":"GG0185J8","text":"The form asks about the patient's ability to manage injectable medications. It specifically addresses whether the patient can reliably and safely prepare and take all prescribed injectable medications, including the administration of the correct dosage at the correct times/intervals. The patient's performance in this area is marked as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125V","prefix":"GG0125V","text":"Does the patient use an assistive device such as a raised toilet seat?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Y","prefix":"GG0125Y","text":"Does the patient use an assistive device such as an oxygen concentrator?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175J8","prefix":"GG0175J8","text":"The question on the form is asking about the patient's ability, once seated in a wheelchair or scooter, to wheel across a street before the traffic light turns red. The answer choices are 'Motorized Wheelchair/Scooter' and 'Most Dependent Performance.'","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185I7","prefix":"GG0185I7","text":"The form asks about the patient's ability to manage their medication, specifically regarding inhalant or mist medications. It wants to know if the patient can prepare and take all prescribed inhalant or mist medications reliably and safely, including the correct dosage at the appropriate times or intervals. It asks for information about their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125U","prefix":"GG0125U","text":"Does the patient use an assistive device such as ramps?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0180A","prefix":"GG0180A","text":"Please ask the patient to describe at least one or two personal priorities in the area of mobility for the next six months. If the patient does not express any personal priorities in this area, please note this below. The answer options would be: A) Improvement in walking, B) Ability to climb stairs, C) Independence in moving, or D) No personal priorities.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0135A","prefix":"GG0135A","text":"Please ask the patient to describe at least one or two personal priorities in the area of self-care for the next six months. If the patient does not express any personal priorities in this area, please note this in their record.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0125K","prefix":"GG0125K","text":"Does the patient use an assistive device such as an electronic bed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125H","prefix":"GG0125H","text":"Does the patient use an assistive device such as a sock aid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920C2","prefix":"F0920C2","text":"The patient requires assistance with Instrumental Activities of Daily Living (IADL), such as making meals, housekeeping, telephone, shopping, or finances, which is currently unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0130A8","prefix":"GG0130A8","text":"The question on the form assesses the patient's ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them. The performance options range from independent to most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125J","prefix":"GG0125J","text":"Does the patient use an assistive device such as a bed rail?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920G1","prefix":"F0920G1","text":"Does the patient require supervision, for example due to safety concerns, and is this supervision paid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0125O","prefix":"GG0125O","text":"Does the patient use an assistive device such as a walk-in or wheel-in shower?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125B3","prefix":"GG0125B3","text":"Does the patient use an assistive device, specifically a walker with wheels?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125G","prefix":"GG0125G","text":"Does the patient use an assistive device such as a reacher or grabber?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170F7","prefix":"GG0170F7","text":"The form asks about the patient's usual performance in terms of their ability to get on and off a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125N","prefix":"GG0125N","text":"Does the patient require an assistive device such as a shower or commode chair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125X","prefix":"GG0125X","text":"Does the patient use an assistive device such as a Continuous Positive Airway Pressure (CPAP) machine?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125C1","prefix":"GG0125C1","text":"Does the patient use an assistive device such as a manual wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170G7","prefix":"GG0170G7","text":"The patient's usual performance indicates their ability to transfer in and out of a car or van on the passenger side. This does not include their ability to open/close the door or fasten the seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125B2","prefix":"GG0125B2","text":"Does the patient use an assistive device such as a walker with a seat?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185I8","prefix":"GG0185I8","text":"The form asks about the patient's ability to manage medication, specifically inhalant or mist medications. It wants to know if the patient can reliably and safely prepare and take all prescribed inhalant/mist medications, including the administration of the correct dosage at the appropriate times and intervals. The answer choices include 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130B7","prefix":"GG0130B7","text":"The form asks about the patient's oral hygiene, specifically their ability to use suitable items to clean their teeth. It also inquires about their use of dentures, if applicable, including their ability to insert and remove the dentures from their mouth, and manage denture soaking and rinsing with the use of equipment. The section is labeled \"Usual Performance.\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125I","prefix":"GG0125I","text":"Does the patient use an assistive device such as orthotics or a brace?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Z_specify","prefix":"GG0125Z_specify","text":"Does the patient use any other type of assistive device? If so, please specify.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170A8","prefix":"GG0170A8","text":"The patient's ability to roll from lying on their back to their left and right side, and return to lying on their back is most dependent on performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130CC7","prefix":"GG0130CC7","text":"The form asks about the patient's usual performance in maintaining toileting hygiene, specifically their ability to maintain perineal/menstrual hygiene and adjust clothing before and after voiding or having a bowel movement. If the patient manages an ostomy, it also includes wiping the opening but does not include managing equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920D1","prefix":"F0920D1","text":"The form asks about the patient's method of medication administration, with options that include oral, inhaled, or injectable medications. The medication administration for the patient is paid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0125E","prefix":"GG0125E","text":"Does the patient use an assistive device, such as a specialized seating pad (for example, an air-filled, gel, or shaped form pad)?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125C2","prefix":"GG0125C2","text":"Does the patient use an assistive device such as a motorized wheelchair and/or scooter?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170L8","prefix":"GG0170L8","text":"The form asks whether the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoors or outdoors. The answer choices for the patient's performance are: Most Independent Performance, Modified Independent, Supervision or Setup, Minimal Assistance, Moderate Assistance, Maximal Assistance, and Most Dependent Performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130CC8","prefix":"GG0130CC8","text":"The form asks the patient about their toileting hygiene, specifically their ability to maintain perineal/menstrual hygiene and adjust their clothes before and after voiding or having a bowel movement. If they are managing an ostomy, they should include their ability to wipe the opening, although managing the equipment is not necessary. The performance rating is either \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185A7","prefix":"GG0185A7","text":"The patient's usual performance demonstrates the ability to plan and prepare all aspects of a light, cold meal such as a bowl of cereal, sandwich, and cold drink.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920G2","prefix":"F0920G2","text":"The form asks if the patient requires supervision due to safety concerns, and specifies if this supervision is unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920C1","prefix":"F0920C1","text":"Does the patient require paid assistance for Instrumental Activities of Daily Living (IADL), such as making meals, housekeeping, using the telephone, shopping, or managing finances?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185L7","prefix":"GG0185L7","text":"The patient's usual performance in complex financial management involves the ability to complete financial decision-making tasks such as budgeting and remembering to pay bills.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185C8","prefix":"GG0185C8","text":"The form inquires about the patient's ability to perform light daily housework in order to maintain a safe home environment such that they are not at risk from harm within their own home. Examples of this housework might include tasks like wiping countertops or doing dishes. The patient's performance is labeled as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125R","prefix":"GG0125R","text":"Does the patient use an assistive device such as a communication device?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920F2","prefix":"F0920F2","text":"Does the patient manage their own equipment, such as oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies, without any payment?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185D8","prefix":"GG0185D8","text":"The form asks about the patient's ability to complete heavier periodic housework, like doing laundry, vacuuming, and cleaning the bathroom, in order to maintain a safe home environment. It also ensures the patient is not at risk for harm within their home. The category marked is 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170B8","prefix":"GG0170B8","text":"The form for the patient includes a question labeled \"Sit to lying\". This refers to the patient's ability to move from sitting on the side of the bed to lying flat on the bed. The performance is categorized as \"Most Dependent\", meaning the patient requires substantial assistance in this task.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130D7","prefix":"GG0130D7","text":"Does the patient have the ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed? Please rate their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0190A","prefix":"GG0190A","text":"Please ask the patient to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the patient does not express any personal priorities in this area, please note this below. Answer: A","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0905A","prefix":"F0905A","text":"Please ask the patient to describe at least one or two personal priorities in the area of their living arrangements for the next six months. If the patient does not express any personal priorities in this area, please note this below. The options are - A.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0920B1","prefix":"F0920B1","text":"Does the patient require mobility assistance, such as assistance with bed mobility, transfers, ambulating, or wheeling? If yes, is this assistance paid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185L8","prefix":"GG0185L8","text":"The form indicates the patient's level of ability in complex financial management, such as completing financial decision-making tasks including budgeting and remembering to pay bills. The patient's performance is recorded as mostly dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130H8","prefix":"GG0130H8","text":"The form asks about the patient's ability to put on and take off socks, shoes, or other appropriate footwear that is necessary for safe mobility, which includes dealing with fasteners, if applicable. The patient's performance in this aspect has been rated as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175H8","prefix":"GG0175H8","text":"The form is asking about the patient's ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter. The answer choices include 'Motorized Wheelchair/Scooter' and 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170A7","prefix":"GG0170A7","text":"The form asks about the patient's usual performance when it comes to their ability to roll from lying on their back to their left and right side, and then return to lying on their back.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185F7","prefix":"GG0185F7","text":"The form asks about the patient's ability to answer a telephone call in their customary manner and maintain the call for one minute or longer. It does not include getting to the phone. The question refers to the patient's usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175I8","prefix":"GG0175I8","text":"The patient questionnaire asked, \"Once the patient is seated in a wheelchair or scooter, do they have the ability to wheel without stopping or resting for 15 minutes (for example, through a department store or supermarket)?\" The answer choices include \"Motorized Wheelchair/Scooter\" and \"Most Dependent Performance.\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0190B","prefix":"GG0190B","text":"Please ask the patient to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the patient does not express any personal priorities in this area, note it below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0925A","prefix":"F0925A","text":"Please ask the patient to describe at least one or two personal priorities for their caregiving arrangement in the next six months. If the patient does not express any personal priorities in this area, please note this below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0925B","prefix":"F0925B","text":"Please ask the patient or resident to describe at least one or two personal priorities in the area of caregiving for the next six months. If the patient or resident does not express any personal priorities in this area, please note this below. The options are:\n\nA. The patient expresses personal priorities in the area of caregiving.\nB. The patient does not express any personal priorities in the area of caregiving.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170V8","prefix":"GG0170V8","text":"The form for the patient asks about his or her ability to carry something in both hands while walking indoors, such as several dishes, a light laundry basket, or a tray with food. The patient's performance in this area is identified as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]}],"_id":"7rQjKG7PYAHe2neub"} {"responseType":"QuestionnaireResponse","id":"his-ha-2.00.0","questionnaire":"HIS-HA-2.00.0","title":"Hospice Item Set - Hospice Admission Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-04-27T18:38:55.449Z","item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"The form asks for the patient's Medicaid number. The patient should enter \"+\" if their Medicaid status is pending, or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-36/A0800","prefix":"A0800","text":"What is the patient's gender? The possible answers could be male, female, or prefer not to say.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record for the patient needs to be specified.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0250","prefix":"A0250","text":"The reason for the patient's assessment needs to be determined.","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"What is the patient's admission date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Where was the patient immediately preceding this admission? Was the patient admitted from another hospital, a nursing home, their residence, or another location?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0550","prefix":"A0550","text":"What is the patient's ZIP code?","type":"text","repeats":false,"readOnly":false,"maxLength":11},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"Does the patient have a National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"What is the patient's CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"The form asks for the patient's suffix.","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A1000","prefix":"A1000","text":"The patient should check all the applicable boxes for their race or ethnicity.","type":"text","repeats":true,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A1400","prefix":"A1400","text":"The patient needs to fill out the payer information and must check all the options that apply to them.","type":"text","repeats":true,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0205","prefix":"A0205","text":"What was the site of service at the patient's admission?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0245","prefix":"A0245","text":"The date when the initial nursing assessment was initiated for the patient.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the patient, resident, or responsible party asked about their preference regarding the use of cardiopulmonary resuscitation (CPR)? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"The date on which the patient or responsible party was first asked about their preference regarding the use of CPR.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the patient, or their responsible party, asked about their preferences regarding life-sustaining treatments other than CPR? Select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"What was the date when the patient or responsible party was first asked about their preferences regarding life-sustaining treatments other than CPR?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the patient or the responsible party asked about their preference regarding hospitalization? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"The date when the patient, resident, or responsible party was first asked about their preference regarding hospitalization is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the patient or their caregiver asked about any spiritual or existential concerns? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"The date on which the patient or caregiver was first asked about spiritual or existential concerns is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-9/I0010","prefix":"I0010","text":"What is the patient's principal diagnosis?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the patient or resident screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"The date of the patient's first screening for pain was:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The severity of the patient's or resident's pain was:","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"What type of standardized pain tool was used for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Is pain an active problem for the patient or resident?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment conducted on the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"When was the patient's comprehensive pain assessment conducted?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"A comprehensive pain assessment was included for the patient where they needed to check all applicable options.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the patient or resident screened for any symptoms of shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"The date of the patient's first screening for shortness of breath was:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate that the patient had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"The form asks if treatment for the patient's shortness of breath was initiated. Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"What is the date when the treatment for shortness of breath was initiated for the patient?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"What types of treatment for shortness of breath have been initiated for the patient? Please check all that apply.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"The date the patient had their opioid treatment initiated or continued is scheduled for:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid medication initiated or continued for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"The date on which the patient's PRN opioid was initiated or continued is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued for the patient? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"The date on which the patient's bowel regimen was initiated or continued is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"The patient must provide their signature and title, as well as complete section A, including the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"The patient is required to provide their signature, title, and date they completed section B.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"The patient needs to provide their signature, title, and date on the completed C section of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"The patient needs to provide their signature, title, and the date on which they completed Section D of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"The patient needs to provide their signature, title, and the sections completed, along with the date when section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"The patient must sign, provide their title, complete all sections of the form, and include the date that each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"The patient needs to provide their signature and title, fill out the necessary sections, and date the section when it's completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"The patient is required to provide their signature, title, and the date they completed Section H on the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"The patient needs to provide their signature, title, and the date they completed section I.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title, complete the sections, and include the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature and title, and complete the sections indicated on the form. The date the section was completed should also be included.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"The patient's form must include their signature and title, the sections filled out, as well as the date each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"The patient needs to provide their signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"The date on which the RN Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false}],"_id":"26o85hhg2erJYKkid"} {"responseType":"QuestionnaireResponse","id":"his-hd-2.00.0","questionnaire":"HIS-HD-2.00.0","title":"Hospice Item Set - Hospice Discharge Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-04-27T18:40:14.338Z","item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"The patient is required to enter a \"+\" if their Medicaid Number is pending or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-36/A0800","prefix":"A0800","text":"The patient's gender is being asked, with the answer choices being male, female, or prefer not to say.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record pertaining to the patient needs to be identified.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0250","prefix":"A0250","text":"What is the reason for the patient's assessment?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"The admission date of the patient is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0270","prefix":"A0270","text":"What is the patient's discharge date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"What is the patient's National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"What is the patient's CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"What is the patient's suffix?","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A2115","prefix":"A2115","text":"What was the patient's reason for discharge?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final three days of their life?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Did a registered nurse visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"The registered nurse visited the patient one day prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"The patient was visited by a registered nurse two days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant one day prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Did the patient visit a physician, nurse practitioner, or physician assistant two days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"The medical social worker visited the patient on the day of their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"The medical social worker visited the patient one day prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"The medical social worker visited the patient two days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Did the patient receive a visit from a chaplain or spiritual counselor on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Did the patient receive a visit from a chaplain or spiritual counselor one day prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Did the patient receive a visit from a Chaplain or Spiritual Counselor two days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Did the Licensed Professional Nurse visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Did the licensed professional nurse visit the patient one day prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Did the Licensed Professional Nurse visit the patient two days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Did an aide visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Did the aide visit the patient one day prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Did the aide visit the patient two days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final seven days of their life? This question refers to the level of care given in the final seven days.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"The patient was visited by a registered nurse three days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"The registered nurse visited the patient four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"The registered nurse visited the patient five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"The registered nurse visited the patient six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Did the patient visit a physician, nurse practitioner, or physician assistant three days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Did the patient visit a physician, nurse practitioner, or physician assistant four days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"The patient was visited by a physician, nurse practitioner, or physician assistant five days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Did the patient visit a physician, nurse practitioner, or physician assistant six days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Did the medical social worker visit the patient three days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"The medical social worker visited the patient four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"The medical social worker visited the patient five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"The medical social worker visited the patient six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Did the patient have a visit from a chaplain or spiritual counselor three days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"The patient's chaplain or spiritual counselor visited four days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"The patient was visited by a Chaplain or Spiritual Counselor five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Did the patient receive a visit from a chaplain or spiritual counselor six days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"The patient was visited by a Licensed Professional Nurse three days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"The patient was visited by a Licensed Professional Nurse four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Did the licensed professional nurse visit the patient five days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"The patient was visited by a Licensed Professional Nurse six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Did the aide visit the patient three days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"The patient received visits from the aide four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Did the aide visit the patient five days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Did the aide visit the patient six days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"The patient is required to provide their signature and title, and to acknowledge the sections and date that the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"The patient is required to provide their signature, title, and the date on which they completed Section B.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"The patient is asked to provide their signature and title in the designated sections, and to also indicate the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"The form for the patient asks for the patient's signature, their title, the sections they have completed, and the date they completed section D.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"The section indicated as \"Signature, Title, Sections, Date Section Completed E\" on the patient's form needs to be filled out.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"The patient's signature, title, and the date of completion are required in section F.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"The patient is required to provide their signature and title in the designated sections and indicate the date when they completed Section G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"The patient's form includes sections for signature, title, and date of completion, all of which must be filled out by Section H.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"The patient must provide their signature, title, date, and completed sections in section I.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title, and complete sections J of the form. This needs to be done by a specific date.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"The sections, signature, title, and the date when the section was completed are required information for patient K's form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"The sections of the form, including the signature, title, and date section, were completed by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"The form requires the patient's signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"The date on which the RN Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false}],"_id":"6MrCm7REjJ3En9Wpi"} {"responseType":"QuestionnaireResponse","id":"irf-pai-ia-3.0","questionnaire":"IRF-PAI-IA-3.0","title":"Inpatient Rehabilitation Facility Patient Assessment Instrument - IRF Admission","description":"Assessment data collected on all Medicare Part A fee-for-service patients who receive services under Part A from an inpatient rehabilitation facility (IRF) at admission and upon discharge.","status":"draft","authored":"2024-04-27T18:34:15.837Z","item":[{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0700","prefix":"A0700","text":"The patient should enter a \"+\" in the Medicaid Number field if the application is pending, or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-38/A0800","prefix":"A0800","text":"The patient's gender is required. Is the patient male or female?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Male"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Female"}}]},{"linkId":"Section-38/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/A1200","prefix":"A1200","text":"What is the patient's marital status? Is he/she single, married, divorced, separated, or widowed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Never married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Widowed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Separated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Divorced"}}]},{"linkId":"Section-38/A0220","prefix":"A0220","text":"What is the admission date for the patient?","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/11","prefix":"11","text":"What is the zip code of the patient's or resident's pre-hospital residence?","type":"text","repeats":false,"readOnly":false,"maxLength":5},{"linkId":"Section-38/13","prefix":"13","text":"The assessment reference date for the patient has been set.","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/14","prefix":"14","text":"The admission class of the patient is categorized under which category?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Initial Rehab"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Evaluation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Readmission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unplanned Discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Continuing Rehabilitation"}}]},{"linkId":"Section-38/17","prefix":"17","text":"Does the patient live at home prior to hospitalization? If the pre-hospital living setting is the patient's home, please code accordingly.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Alone"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Family / Relatives"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Friends"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Attendant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Other"}}]},{"linkId":"Section-38/15A","prefix":"15A","text":"From where was the patient admitted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}}]},{"linkId":"Section-38/16A","prefix":"16A","text":"The patient's pre-hospital living setting is required. Please use codes from the 'Admit From' category.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}}]},{"linkId":"Section-38/1A","prefix":"1A","text":"What is the name of the facility or provider for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":50},{"linkId":"Section-38/5B","prefix":"5B","text":"What is the patient's or resident's identification number?","type":"text","repeats":false,"readOnly":false,"maxLength":50},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Please check all the boxes that apply to the patient's race and ethnicity.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}]},{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Please record the most recent height measurement in inches for the patient since their admission.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"The patient's weight in pounds should be based on the most recent measure taken within the specified time period. The weight measurement must be executed consistently, adhering to the standard practice of the facility or setting, such as in the morning after voiding, before meals, with shoes off, etc.","type":"integer","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-41/21A","prefix":"21A","text":"The impairment group upon admission refers to the condition that required the patient to be admitted to rehabilitation; this should be coded according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-41/23","prefix":"23","text":"When did the impairment of the patient first begin?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Does the patient have any arthritis conditions recorded in either the impairment group, etiologic diagnosis, or comorbid conditions that meet all the regulatory requirements for Inpatient Rehabilitation Facility (IRF) classification?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-41/22A","prefix":"22A","text":"The form asks for the patient's etiologic diagnosis A.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/22B","prefix":"22B","text":"The form asks the patient for their etiologic diagnosis B.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/22C","prefix":"22C","text":"The form for the patient includes a section on etiologic diagnosis C.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24A","prefix":"24A","text":"Does the patient have Comorbid Condition A?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24B","prefix":"24B","text":"Does the patient have Comorbid Condition B?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24C","prefix":"24C","text":"Does the patient have Comorbid Condition C?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24D","prefix":"24D","text":"Does the patient have a comorbid condition D?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24E","prefix":"24E","text":"Does the patient have a comorbid condition E?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24F","prefix":"24F","text":"Does the patient have a comorbid condition F?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24G","prefix":"24G","text":"Does the patient have a comorbid condition G?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24H","prefix":"24H","text":"Does the patient have a comorbid condition H? Please select 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24I","prefix":"24I","text":"Does the patient have a comorbid condition? Please select either 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24J","prefix":"24J","text":"Does the patient have comorbid condition J?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24K","prefix":"24K","text":"Does the patient have a comorbid condition K?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24L","prefix":"24L","text":"Does the patient have any comorbid conditions? Please list them.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24M","prefix":"24M","text":"The patient has a comorbid condition labelled as M.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24N","prefix":"24N","text":"Does the patient have any comorbid conditions? Please select 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24O","prefix":"24O","text":"Does the patient have any comorbid conditions?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24P","prefix":"24P","text":"Does the patient have a comorbid condition P?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Does the patient have a comorbid condition?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24R","prefix":"24R","text":"Does the patient have a comorbid condition R?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24S","prefix":"24S","text":"The form inquires about the patient's comorbid conditions.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24T","prefix":"24T","text":"Does the patient have a comorbid condition? Please choose one: Yes or No.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24U","prefix":"24U","text":"The patient has a comorbid condition, referred to as Condition U.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24V","prefix":"24V","text":"Does the patient have a comorbid condition V?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24W","prefix":"24W","text":"Does the patient have a comorbid condition W?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24X","prefix":"24X","text":"Does the patient have a comorbid condition X?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Does the patient have a comorbid condition labeled as Y?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-40/20A","prefix":"20A","text":"The primary source of information about the patient is the patient themselves.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}]},{"linkId":"Section-40/20B","prefix":"20B","text":"The form asks the patient to provide a secondary source of information.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}]},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"The patient's ability to express ideas and wants, considering both verbal and non-verbal expression and excluding language barriers, is being evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}]},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Does the patient understand verbal and non-verbal content with the use of a hearing aid or device, excluding language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}]},{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should a brief interview for mental status be conducted? An attempt should be made to conduct an interview with all patients or residents.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-3/C0200","prefix":"C0200","text":"The form asks the patient: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" The form then records the number of words the patient repeated after the first attempt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}]},{"linkId":"Section-3/C0500","prefix":"C0500","text":"The BIMS Summary Score requires the addition of scores for the Brief Interview for Mental Status questions, with the total score filled in, ranging from 00-15. If the patient or resident was unable to complete the interview, enter 99.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the staff conduct an assessment for the patient's mental status?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}]},{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"The form asks the patient, \"Please tell me what year it is right now,\" to determine if they are able to accurately report the current year.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}]},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"The form asks the patient: \"What month are we in right now?\" The patient is expected to be able to report the correct month.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}]},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"The form asks the patient, \"What day of the week is today?\" The patient is then expected to be able to report the correct day of the week.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}]},{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"The patient is able to recall the word \"sock\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"The patient is able to recall the color \"blue\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Is the patient able to recall the word \"bed\"?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0900","prefix":"C0900","text":"The form asked to check all the items that the patient or resident was normally able to recall, indicating their memory or recall ability.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}]},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"The question on the form asks about the patient's ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them. This refers to their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"The patient's oral hygiene refers to their ability to use suitable items to clean their teeth. If applicable, their ability to handle dentures is evaluated by their capability to insert and remove them into and from the mouth, as well as successfully managing the soaking and rinsing of the dentures with the use of equipment. This is part of their admission performance assessment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"Does the patient have the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement? If the patient is managing an ostomy, does this include wiping the opening but not managing the equipment? Please assess their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"The discharge goal for the patient or resident is to gain the ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"The patient's oral hygiene pertains to their ability to use suitable items to clean their teeth. If applicable, their denture care involves the ability to insert and remove dentures into and from the mouth, as well as managing denture soaking and rinsing with the use of equipment. The discharge goal is to ensure these abilities.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"The discharge goal is for the patient to have the ability to maintain perineal hygiene, adjust their clothes before and after voiding or having a bowel movement. If they are managing an ostomy, this includes wiping the opening but not managing the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"The form asks about the patient's ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed during their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"The form asks about the patient's ability to move from sitting on the side of the bed to lying flat on the bed at the time of admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"The form asks about the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. This is referred to as 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"The discharge goal for the patient is to have the ability to roll from lying on their back to their left and right side, and then return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"The discharge goal for the patient includes the ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"The patient's discharge goal is the ability to move from lying on the back to sitting on the side of the bed without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"Does the patient have the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"The patient's admission performance includes the ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"The admission form poses a question regarding the patient's ability to transfer to and from a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"The question on the form asks about the patient's admission performance, specifically their ability to walk at least 10 feet in a room, corridor, or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"The form asks about the patient's admission performance, specifically their ability to walk at least 50 feet and make two turns once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"The form asks about the patient's admission performance, specifically, once standing, does the patient have the ability to walk at least 150 feet in a corridor or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"Once the patient is seated in the wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. This is a requirement for admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"The form asks about the patient's admission performance regarding their ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K3","prefix":"GG0170K3","text":"Does the patient have the ability, once standing, to walk at least 150 feet in a corridor or similar space? This will be evaluated as part of their discharge performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"The discharge goal for the patient is to develop the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"The discharge goal for the patient is to be able to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"The discharge goal for the patient is to have the ability to get on and off a toilet or commode independently.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"The discharge goal for the patient is to achieve the ability to walk at least 10 feet once standing, whether it's in a room, corridor, or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"The form asks if, once standing, the patient has the ability to walk at least 50 feet and make two turns. The answer options for this question are \"Yes\" or \"No\". This information will help set a discharge goal for the patient.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"The form inquires if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The goal is to attain this ability by the time of discharge.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"The discharge goal for the patient is to be able once seated in the wheelchair or scooter, to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"The discharge goal for the patient is to have the ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the patient or resident use a wheelchair and/or scooter upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Please indicate the type of wheelchair or scooter that the patient uses upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"The patient is required to indicate the type of wheelchair or scooter used upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"The form inquires about the patient's ability to bathe themselves, which includes washing, rinsing, and drying themselves, excluding washing of the back and hair. It does not consider the ability to transfer in or out of the tub or shower. This information is required for the Admission Performance assessment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"The admission performance form inquires about the patient's ability to dress and undress above the waist, including the handling of fasteners if applicable, under the section labeled 'Upper Body Dressing'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"On the admission form, it asks about the patient's ability to dress and undress below the waist, including handling fasteners. It does not include dealing with footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"The form asks about the patient's ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable. This is in reference to their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"The form asks about the patient's ability to transfer in and out of a car or van from the passenger side upon admission. This does not include the patient's ability to open or close the door or fasten their seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"The form asks about the patient's ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel, in terms of their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"The form asks about the patient's ability to go up and down a curb and/or up and down one step, as a measure of their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170N1","prefix":"GG0170N1","text":"The patient's admission performance indicates their ability to go up and down four steps, either with or without the aid of a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170O1","prefix":"GG0170O1","text":"The question on the form asks about the patient's ability to go up and down 12 steps with or without a rail. The label is \"Admission Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170P1","prefix":"GG0170P1","text":"The form asks about the patient's ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor. This question is referred to as the 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130E2","prefix":"GG0130E2","text":"The form asks about the patient's ability to shower or bathe themselves, which includes washing, rinsing, and drying, but excludes washing of the back and hair. It is important to note, this does not include the patient's ability to transfer in and out of the tub or shower. The focus of this question is to understand the patient's discharge goal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130F2","prefix":"GG0130F2","text":"The patient's discharge goal includes developing the ability to dress and undress themselves above the waist, including managing fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130G2","prefix":"GG0130G2","text":"The discharge goal for the patient is to develop the ability to dress and undress below the waist, including handling fasteners, but this does not include managing footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130H2","prefix":"GG0130H2","text":"The discharge goal for the patient is to develop the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including managing fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"The patient's discharge goal is to be able to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten the seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"The patient's discharge goal is to have the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoors or outdoors.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"The discharge goal for the patient is the ability to go up and down a curb and/or up and down one step.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"The discharge goal for the patient is to develop the ability to go up and down four steps, with or without the assistance of a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"The discharge goal for the patient is to have the ability to go up and down 12 steps with or without a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"The discharge goal for the patient is to develop the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Please code the patient's or resident's need for assistance with activities such as bathing, dressing, using the toilet, and eating prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"The form asks for the patient's or resident's level of need for assistance with indoor mobility, specifically walking from room to room, prior to the current illness, exacerbation, or injury. This includes whether they required a device such as a cane, crutch, or walker.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Please code the patient's or resident's need for assistance with internal or external stairs, whether with or without a device such as a cane, crutch, or walker, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Please code the patient's need for assistance with planning regular tasks, such as shopping or remembering to take medication, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"The form asks for information about the devices and aids that the patient or resident was using prior to their current illness, exacerbation, or injury. It requests that all applicable options be checked.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Please select the category that best describes the bowel continence of the patient or resident.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}]},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Please select the one category that best describes the patient's bladder continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}]},{"linkId":"Section-9/I0000","prefix":"I0000","text":"The form asks the patient to check all active diagnoses they have had in the last 7 days. It should be noted that the diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-10/J1750","prefix":"J1750","text":"Does the patient or resident have a history of falls, specifically, have they experienced two or more falls in the past year or any fall that resulted in injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}]},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Did the patient have any major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}]},{"linkId":"Section-11/K0110","prefix":"K0110","text":"Indicate the patient's usual ability to swallow by checking all applicable boxes pertaining to their swallowing and nutritional status.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}]},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Does the patient or resident have one or more unhealed pressure ulcers or injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"The form is asking the patient to report the number of Stage 2 pressure ulcers they currently have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"The patient has been asked to indicate the number of Stage 3 pressure ulcers they have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"The patient has a certain number of stage 4 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"How many unstageable pressure ulcers or injuries does the patient have due to a non-removable dressing or device?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"The form is asking the patient about the number of unstageable pressure ulcers they have due to the coverage of the wound bed by slough and/or eschar.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"The patient has a number of unstageable pressure injuries presenting as deep tissue injury.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"The form is asking the patient to disclose the number of Stage 1 pressure injuries they have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Did a complete drug regimen review conducted for the patient identify any potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}]},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Did the facility or setting contact a physician or a designated representative by midnight of the next calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues for the patient?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-15/O0100","prefix":"O0100","text":"The patient should check all of the following special treatments, procedures, and programs that were performed on them.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}]},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"The form for the patient includes sections such as the signature, title, and date section A that need to be completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"The patient must provide their signature, title, and date in the sections where the section completion is indicated by a 'B'.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"The sections labeled \"Signature\", \"Title\", \"Sections\", and \"Date Section Completed C\" must be filled out by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"The sections of the form completed by the patient are signed and dated, with their title also mentioned.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"The patient should fill out the signature, title, and sections, then indicate the date the section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"The patient's signature, title, and the date the form sections were completed are required in section F.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"The patient needs to provide their Signature, Title, and complete the Sections mentioned in the form, including the Date Section Completed G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"The patient needs to include their signature, title, and date on the completed sections H of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"The patient needs to provide their signature and title, complete the sections, and indicate the date on which the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"The patient is required to provide their signature, title, and the date on which the sections were completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature, their title, and fill out the sections on the form, indicating the date each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"The patient's form includes a signature, title, sections, and a section indicating the date the form was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100}],"_id":"xacTfrWmhnf9wtKcN"} {"id":"pbupcoBuWyD8N7qtY","responseType":"QuestionnaireResponse","status":"draft","authored":"2024-04-27T18:36:21.698Z","item":[{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0800","prefix":"A0800","text":"What is the patient's gender?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Female"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}]},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1100B","prefix":"A1100B","text":"What is the patient's preferred language?","type":"text","repeats":false,"readOnly":false,"maxLength":15},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"The form for the patient asks for their suffix.","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"What is the patient's National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-3/C1610E1","prefix":"C1610E1","text":"The patient's alertness level is normal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the patient or resident use a wheelchair and/or scooter upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"How many Stage 1 pressure injuries does the patient have?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"The patient has a certain number of stage 4 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0200","prefix":"A0200","text":"The type of provider for the patient needs to be specified.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Long-Term Care Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28448-1","display":"Long-term care hospital "}}]},{"linkId":"Section-15/O0250B","prefix":"O0250B","text":"What is the date the patient received the influenza vaccine?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0100C","prefix":"A0100C","text":"The patient's State Medicaid Facility or Provider Number is required.","type":"text","repeats":false,"readOnly":false,"maxLength":15},{"linkId":"Section-9/I0050","prefix":"I0050","text":"Please indicate the primary medical condition category for the patient or resident.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Acute Onset Respiratory Condition (e.g., aspiration and specified bacterial pneumonias)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27513-3","display":"Acute onset respiratory condition (e.g., aspiration and specified bacterial pneumonias)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Chronic Respiratory Condition (e.g., chronic obstructive pulmonary disease)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27514-1","display":"Chronic respiratory condition (e.g., chronic obstructive pulmonary disease)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Acute Onset and Chronic Respiratory Conditions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27515-8","display":"Acute onset and chronic respiratory conditions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Chronic Cardiac Condition (e.g., heart failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27516-6","display":"Chronic cardiac condition (e.g., heart failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Other Medical Condition. If \"Other Medical Condition\", enter ICD code in the boxes."}},{"valueCoding":{"system":"http://loinc.org","code":"LA16346-1","display":"Other medical condition"}}]},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"The patient has a certain number of Stage 2 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0210","prefix":"A0210","text":"The assessment reference date refers to the patient's observation end date.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1400","prefix":"A1400","text":"The patient needs to provide their payer information by checking all the boxes that apply.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Medicare (traditional fee-for-service)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6259-1","display":"Medicare (traditional fee-for-service)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Medicare (managed care/Part C/Medicare Advantage)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27554-7","display":"Medicare (managed care/Part C/Medicare Advantage)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Medicaid (traditional fee-for-service)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6257-5","display":"Medicaid (traditional fee-for-service)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Medicaid (managed care)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27556-2","display":"Medicaid (managed care)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Workers' compensation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6452-2","display":"Workers' compensation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Title programs (e.g., Title III, V, or XX)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6398-7","display":"Title programs (e.g., Title III, V, or XX)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Other government (e.g., TRICARE, VA, etc.)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10049-7","display":"Other government (e.g., TRICARE, VA, etc.)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Private insurance/Medigap"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10061-2","display":"Private insurance/Medigap"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Private managed care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27561-2","display":"Private managed care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Self-pay"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6369-8","display":"Self-pay"}},{"valueCoding":{"system":"http://del.cms.gov","code":"K","display":"No payer source"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18995-3","display":"No payor source"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"Other"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}]},{"linkId":"Section-15/O0100","prefix":"O0100","text":"Please check all of the following special treatments, procedures, and programs that were performed on the patient.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Non-invasive Ventilator (BIPAP, CPAP)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27542-2","display":"Non-invasive ventilator (BIPAP, CPAP)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"IV Medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27972-1","display":"IV medications, (if checked, please specify below)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H2a","display":"Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28269-1","display":"Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Dialysis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA7216-0","display":"Dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-36/A0250","prefix":"A0250","text":"What is the reason for the patient's assessment?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Admission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10922-5","display":"Admission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Planned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18067-1","display":"Planned discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"12","display":"Expired"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10325-1","display":"Expired"}}]},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record for the patient needs to be identified.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Add new assessment/record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27573-7","display":"Add new assessment/record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Modify existing record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12664-1","display":"Modify existing record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Inactivate existing record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12665-8","display":"Inactivate existing record"}}]},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"The sections were completed and dated by the patient, who then signed and titled the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"The patient has a certain number of unstageable pressure injuries that are presenting as deep tissue injury.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Where was the patient immediately preceding this admission? Was the patient admitted from home, another healthcare facility, or somewhere else?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11501-6","display":"Community residential setting (e.g., private home, assisted living, group home, adult foster care)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Long-term care facility (LTC)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18066-3","display":"Long-term care facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Hospital emergency department"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11504-0","display":"Hospital emergency department"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Short-stay acute hospital (IPPS)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10078-6","display":"Short-stay acute hospital (IPPS)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"Inpatient rehabilitation facility or unit (IRF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27548-9","display":"Inpatient rehabilitation facility or unit (IRF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"Psychiatric hospital or unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10065-3","display":"Psychiatric hospital or unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Intellectually Disabled/Developmentally Disabled (ID/DD) facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28224-6","display":"Intellectually disabled/developmentally disabled (ID/DD) facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Hospice"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6216-1","display":"Hospice"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-15/O0250A","prefix":"O0250A","text":"Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"The patient must provide their signature, title, and the date on which they completed Section I of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"The patient needs to provide their Signature, Title, and the Date they completed Section D.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-2/B0100","prefix":"B0100","text":"The patient is in a comatose state with no discernible consciousness, persisting in a vegetative state.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Please select the one category that best describes the patient's bladder continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}]},{"linkId":"Section-3/C1610A","prefix":"C1610A","text":"Is there evidence of an acute change in the patient's or resident's mental status from their baseline?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Did a complete drug regimen review for the patient identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}]},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Does the patient understand both verbal and non-verbal content with the use of their hearing aid or device, excluding any language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}]},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Does the patient express their ideas and wants, considering both verbal and non-verbal expression and excluding language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}]},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"The discharge goal for the patient is to have the ability to get on and off a toilet or commode independently.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"The form asks about the patient's admission performance regarding their ability to transfer to and from a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-36/A1200","prefix":"A1200","text":"What is the patient's marital status? Is the patient single, married, divorced, separated, or widowed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Divorced"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}]},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"The discharge goal for the patient is to have the ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0500B","prefix":"Z0500B","text":"The date on which the Registered Nurse Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-15/O0150B","prefix":"O0150B","text":"The patient was assessed for readiness for spontaneous breathing trial (SBT) by the second day of their Long Term Care Hospital (LTCH) stay.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Does this patient or resident have one or more unhealed pressure ulcers or injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"The signature, title, and date of the section completed F were filled out by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-36/A1100A","prefix":"A1100A","text":"Does the patient need or want an interpreter to communicate with a doctor or health care staff? Please indicate 'yes' or 'no'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Unable to determine"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11137-9","display":"Unable to determine"}}]},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"The patient completed section B and then they signed and dated the form, also providing their title.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-15/O0150A","prefix":"O0150A","text":"Was the patient on invasive mechanical ventilator support upon admission to the Long-Term Care Hospital?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No, not on invasive mechanical ventilation support upon admission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28329-3","display":"No, not on invasive mechanical ventilation support"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, weaning"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28330-1","display":"Yes, weaning"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, non-weaning"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28331-9","display":"Yes, non-weaning"}}]},{"linkId":"Section-9/I0050A","prefix":"I0050A","text":"If the patient has an \"Other Medical Condition\", they should enter the ICD code in the provided boxes.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"How many unstageable pressure ulcers does the patient have due to the coverage of the wound bed by slough and/or eschar?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"The patient's signature, title, and the date are required in the completed Section G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"The form requires the patient's signature, title, the sections they completed, and the date on which Section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-11/K0200A","prefix":"K0200A","text":"Please record the most recent measurement of the patient's height in inches since their admission.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"The admission date of the patient is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-19/Z0500A","prefix":"Z0500A","text":"The form requires the patient's signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Please select the one category that best describes the patient's or resident's bowel continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}]},{"linkId":"Section-36/A1000","prefix":"A1000","text":"The patient should check all the applicable options for their race or ethnicity.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}]},{"linkId":"Section-3/C1610B","prefix":"C1610B","text":"Did the patient's abnormal behavior fluctuate during the day, that is, did it tend to come and go or increase and decrease in severity?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title in the designated sections and also indicate the date when each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"The form asks if, once standing, the patient has the ability to walk at least 50 feet and make two turns for their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"How many Stage 3 pressure ulcers does the patient have?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"The form asks about the patient's admission performance regarding their ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"The form asks about the patient's admission performance in regards to their ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"The discharge goal for the patient is to gain the ability to stand up and walk at least 10 feet in a room, corridor, or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"The form asks about the patient's admission performance in terms of their ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-3/C1610E2","prefix":"C1610E2","text":"Is the patient vigilant (hyperalert), lethargic (drowsy, easily aroused), in a stupor (difficult to arouse), or in a coma (unarousable)?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature and title, and complete the relevant sections. The date when the section was completed is also required.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"The discharge goal for the patient is to achieve the ability to walk at least 150 feet in a corridor or similar space, once they are able to stand.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"The patient must provide their signature and title, as well as complete the sections indicated. The date when the section was completed has to be marked as 'A'.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0130D1","prefix":"GG0130D1","text":"The admission performance form inquires about the patient's ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"The form asks about the patient's admission performance, specifically inquiring about their ability to stand and walk at least 150 feet in a corridor or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"The discharge goal for the patient or resident is to gain the ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"The discharge goal for the patient is to once be seated in a wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"The form asks about the patient's admission performance, specifically whether, once seated in a wheelchair or scooter, they are able to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"The section labeled \"Signature, Title, Sections, Date Section Completed L\" on the patient's form needs to be filled out.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"How many unstageable pressure ulcers or injuries does the patient have due to a non-removable dressing or device?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-15/O0150C","prefix":"O0150C","text":"The patient was deemed medically ready for Spontaneous Breathing Trial (SBT) by day 2 of their Long Term Care Hospital (LTCH) stay.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"The form asks about the patient's admission performance in relation to their ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-9/I0000","prefix":"I0000","text":"Has the patient had any active diagnoses in the last 7 days? Please check all that apply. The diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0103","display":"Metastatic Cancer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28289-9","display":"Metastatic cancer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0104","display":"Severe Cancer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28290-7","display":"Severe cancer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0605","display":"Severe Left Systolic/Ventricular Dysfunction (known ejection fraction <= 30%)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28298-0","display":"Severe left systolic/ventricular dysfunction (known ejection fraction <= 30%)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1501","display":"Chronic Kidney Disease, Stage 5"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27518-2","display":"Chronic kidney disease, stage 5"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1502","display":"Acute Renal Failure"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27519-0","display":"Acute renal failure"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2101","display":"Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27520-8","display":"Septicemia, sepsis, systemic inflammatory response syndrome/shock"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2600","display":"Central Nervous System Infections, Opportunistic Infections, Bone/Joint/Muscle Infections/Necrosis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27521-6","display":"Central nervous system infections, opportunistic infections, bone/joint/muscle infections/necrosis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27539-8","display":"Diabetes mellitus (DM)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4100","display":"Major Lower Limb Amputation (e.g., above knee, below knee)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27522-4","display":"Major lower limb amputation (e.g., above knee, below knee)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4501","display":"Stroke"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22099-8","display":"Stroke"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4801","display":"Dementia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA20372-1","display":"Dementia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4900","display":"Hemiplegia or Hemiparesis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27523-2","display":"Hemiplegia or hemiparesis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5000","display":"Paraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA25276-9","display":"Paraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5101","display":"Complete Tetraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27528-1","display":"Complete tetraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5102","display":"Incomplete Tetraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27529-9","display":"Incomplete tetraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5110","display":"Other Spinal Cord Disorder/Injury (e.g., myelitis, cauda equina syndrome)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27530-7","display":"Other spinal cord disorder/injury (e.g., myelitis, cauda equina syndrome)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5200","display":"Multiple Sclerosis (MS)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27531-5","display":"Multiple sclerosis (MS)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5250","display":"Huntington's Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27532-3","display":"Huntington's disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5300","display":"Parkinson's Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27533-1","display":"Parkinson's disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5450","display":"Amyotrophic Lateral Sclerosis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27534-9","display":"Amyotrophic lateral sclerosis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5455","display":"Other Progressive Neuromuscular Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28291-5","display":"Other progressive neuromuscular disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5460","display":"Locked-In State"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27535-6","display":"Locked-in state"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5470","display":"Severe Anoxic Brain Damage, Cerebral Edema, or Compression of Brain"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27536-4","display":"Severe anoxic brain damage, cerebral edema, or compression of brain"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5480","display":"Other Severe Neurological Injury, Disease, or Dysfunction"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28292-3","display":"Other severe neurological injury, disease, or dysfunction"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5601","display":"Malnutrition (protein or calorie)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27537-2","display":"Malnutrition (protein or calorie)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5602","display":"At Risk for Malnutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27538-0","display":"At risk for malnutrition"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7100","display":"Lung Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28293-1","display":"Lung transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7101","display":"Heart Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28294-9","display":"Heart transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7102","display":"Liver Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28295-6","display":"Liver transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7103","display":"Kidney Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28296-4","display":"Kidney transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7104","display":"Bone Marrow Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28297-2","display":"Bone marrow transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-36/A0700","prefix":"A0700","text":"The patient should enter a \"+\" in the Medicaid Number section if their Medicaid application is pending, or \"N\" if they are not a recipient of Medicaid.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"The discharge goal for the patient pertains to their ability to transfer to and from a bed to a chair, which could also include a wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"The discharge goal for the patient is the ability to transition from lying on their back to sitting on the side of the bed without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Please code the patient's or resident's need for assistance with walking from room to room, with or without a device such as a cane, crutch, or walker, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - a helper completed the activity for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-3/C1610D","prefix":"C1610D","text":"Was the patient's or resident's thinking disorganized or incoherent, characterized by rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switches from subject to subject?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"The discharge goal for the patient is to attain the ability to stand and walk at least 50 feet, making two turns once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"The sections of the form, including the signature and title sections, were completed by the patient on the date indicated in the \"Date Section Completed H\".","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Does the patient have the ability to walk at least 10 feet in a room, corridor, or similar space once they are standing? Select from the following options for their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Did the facility or setting contact a physician, or the physician's designee, by midnight of the next calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"The discharge goal for the patient pertains to their ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, which is referred to as \"sit to stand\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"The discharge goal for the patient includes their ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If they are managing an ostomy, this will also include wiping the opening, but not managing the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"The form is questioning the patient's ability, once seated in a wheelchair or scooter, to wheel at least 150 feet in a corridor or similar space. This is a discharge goal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-3/C1610C","prefix":"C1610C","text":"Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? The possible answers could be 'Yes', 'No', or 'Sometimes'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-15/O0150D","prefix":"O0150D","text":"Is there documentation of the reason or reasons in the patient's or resident's medical record that indicates why the patient or resident was deemed medically unready for SBT by the second day of their stay at the Long-Term Care Hospital?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0130D2","prefix":"GG0130D2","text":"The discharge goal for the patient is to have the ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-15/O0250C","prefix":"O0250C","text":"If the patient has not received the influenza vaccine, please state the reason. The options may include: a) allergic to the vaccine, b) vaccine not available, c) personal beliefs, or d) other reasons.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"{Patient/resident} not in facility during this year's influenza vaccination season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26745-2","display":"Patient not in this facility during this year's influenza vaccination season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Received outside of this facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA184-4","display":"Received outside of this facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Not eligible - medical contraindication"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11091-8","display":"Not eligible - medical contraindication"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Offered and declined"}},{"valueCoding":{"system":"http://loinc.org","code":"LA186-9","display":"Offered and declined"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Not offered"}},{"valueCoding":{"system":"http://loinc.org","code":"LA187-7","display":"Not offered"}},{"valueCoding":{"system":"http://del.cms.gov","code":"6","display":"Inability to obtain influenza vaccine due to a declared shortage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26746-0","display":"Inability to obtain influenza vaccine due to a declared shortage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"The question on the form refers to the patient or resident's eating abilities, specifically their ability to utilize appropriate utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is presented to them. This is evaluated based on their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-15/O0150E","prefix":"O0150E","text":"If the patient or resident was deemed medically ready for a Spontaneous Breathing Trial (SBT), was the SBT performed by the second day of their Long Term Care Hospital (LTCH) stay?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"The question on the form assesses the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. The label for this section is 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"The patient's admission performance is evaluated based on their ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If the patient is managing an ostomy, the evaluation includes their ability to wipe the opening but not manage the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"The discharge goal for the patient is to have the ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"The patient's oral hygiene refers to their ability to use suitable items to clean their teeth. If applicable, the patient's ability to handle dentures includes inserting and removing dentures from their mouth and managing denture soaking and rinsing with the use of equipment. The discharge goal needs to be determined.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-11/K0200B","prefix":"K0200B","text":"The patient's weight in pounds should be based on the most recent measure taken in the last specified number of days. The weight must be measured consistently, in accordance with the standard practice of the facility or setting, which may include measurements in the morning after voiding, before meals, with shoes off, etc.","type":"integer","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"The form inquires about the patient's admission performance concerning their ability to roll from lying on their back to their left and right side, and then return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"The patient's oral hygiene pertains to their ability to use suitable items to clean their teeth. If applicable, their use of dentures involves their ability to insert and remove dentures into and from the mouth, as well as manage denture soaking and rinsing with the use of equipment. This information was gathered from their performance upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Please indicate the devices and aids that the patient or resident had used prior to their current illness, exacerbation, or injury. Check all that apply.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]}],"_id":"fmXmEYnQkeqiXShAR"} {"responseType":"QuestionnaireResponse","id":"OASIS-DAH-D1-012020","questionnaire":"OASIS-DAH-D1-012020","title":"Outcome and Assessment Information Set - Death at Home","description":"Data set for use in home health agencies (HHAs), State agencies, software vendors, professional associations and other Federal agencies in implementing and maintaining OASIS.","status":"draft","authored":"2024-04-27T18:41:02.853Z","item":[{"linkId":"Section-21/M0080","prefix":"M0080","text":"The discipline of the person who is completing the assessment for the patient is required.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"RN"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"PT"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"SLP/ST"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"OT"}}]},{"linkId":"Section-21/M0090","prefix":"M0090","text":"The date the assessment was completed for the patient.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-21/M0100_","prefix":"M0100_","text":"This assessment is currently being completed for the following reason pertaining to the patient.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA6390-4","display":"Start of care - further visits planned"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6366-4","display":"Resumption of care (after inpatient stay)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6355-7","display":"Recertification (follow-up) reassessment"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6312-8","display":"Other follow-up"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6402-7","display":"Transferred to an inpatient facility - patient not discharged from agency"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6401-9","display":"Transferred to an inpatient facility - patient discharged from agency"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6179-1","display":"Death at home"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6184-1","display":"Discharge from agency"}}]},{"linkId":"Section-20/A0100A","prefix":"A0100A","text":"Does the patient have a National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-20/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-20/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0700","prefix":"A0700","text":"The patient's Medicaid number should be entered in the provided space. If the Medicaid application is pending, enter \"+\". If the patient is not a Medicaid recipient, enter \"N\".","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-20/A0800","prefix":"A0800","text":"What is the patient's gender? The possible answers are male, female, or prefer not to say.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}]},{"linkId":"Section-20/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0014","prefix":"M0014","text":"In which state does the patient currently reside?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-20/M0016","prefix":"M0016","text":"What is the patient's Branch ID Number?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-20/M0020","prefix":"M0020","text":"What is the patient's or resident's ID number?","type":"text","repeats":false,"readOnly":false,"maxLength":20},{"linkId":"Section-20/M0030","prefix":"M0030","text":"What is the start of care date for the patient?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0032","prefix":"M0032","text":"The date of the patient's resumption of care is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0050","prefix":"M0050","text":"What is the patient's state of residence?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-20/A0550","prefix":"A0550","text":"What is the patient's or resident's ZIP code?","type":"text","repeats":false,"readOnly":false,"maxLength":11},{"linkId":"Section-20/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-20/A0500C","prefix":"A0500C","text":"The patient's last name is required.","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-20/A0500D","prefix":"A0500D","text":"What is the patient's suffix?","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-35/M0906","prefix":"M0906","text":"The form asks for the date of the patient's or resident's discharge, transfer, or death at home to be entered in the \"Discharge/Transfer/Death Date\" field.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-31/N2005","prefix":"N2005","text":"Did the facility or setting contact and complete the actions prescribed or recommended by the physician, or the physician's designee, by midnight of the next calendar day each time potential clinically significant medication issues were identified for the patient since their admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27681-8","display":"NA-There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications"}}]},null,{"linkId":"Section-10/J1900A","prefix":"J1900A","text":"The patient exhibits no injury - there is no evidence of any injury noted on the physical assessment performed by the nurse or primary care clinician; the patient has made no complaints of pain or injury; moreover, there has been no change in the patient's behavior after the fall.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]},{"linkId":"Section-10/J1900B","prefix":"J1900B","text":"The form asks whether the patient has any minor injuries, including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains, or any fall-related injury that has caused them to complain of pain.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]},{"linkId":"Section-10/J1900C","prefix":"J1900C","text":"Has the patient had any major injuries such as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]}],"_id":"o4Tf9K9cjeagFS4uB"} {"resourceType":"QuestionnaireResponse","id":"OASIS-E-012023-1","questionnaire":"OASIS-E-012023","title":"Outcome and Assessment Information Set (E)","status":"draft","authored":"2024-06-05T20:27:15.723Z","item":[{"repeats":false,"linkId":"Section A. Administrative Information /A1005","prefix":"A1005","readOnly":false,"text":"Ethnicity. Are you of Hispanic, Latino/a, or Spanish origin?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"No, not of Hispanic, Latino/a, or Spanish origin"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Yes, Mexican, Mexican American, Chicano/a"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Yes, Puerto Rican"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Yes, Cuban"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Yes, another Hispanic, Latino, or Spanish origin"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"{Patient/Resident/Person} unable to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"{Patient/Resident/Person} declines to respond"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A1010","prefix":"A1010","readOnly":false,"text":"Race. What is your race?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"White"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Asian Indian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Chinese"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Filipino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Japanese"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Korean"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Vietnamese"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Other Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"K","display":"Native Hawaiian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"L","display":"Guamanian or Chamorro"}},{"valueCoding":{"system":"http://del.cms.gov","code":"M","display":"Samoan"}},{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"{Patient/Resident/Person} unable to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"{Patient/Resident/Person} declines to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A1110","prefix":"A1110","readOnly":false,"text":"Language","type":"question"},{"repeats":false,"linkId":"Section A. Administrative Information /A1110A","prefix":"A1110A","readOnly":false,"text":"What is your preferred language?","type":"text"},{"repeats":false,"linkId":"Section A. Administrative Information /A1110B","prefix":"A1110B","readOnly":false,"text":"Do you need or want an interpreter to communicate with a doctor or health care staff?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Unable to determine"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A1250","prefix":"A1250","readOnly":false,"text":"Transportation (from NACHC). Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed from daily living? ","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Yes, it has kept me from medical appointments or from getting my medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"{Patient/Resident/Person} unable to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"{Patient/Resident/Person} declines to respond"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2120","prefix":"A2120","readOnly":false,"text":"Provision of Current Reconciled Medication List to Subsequent Provider at Transfer. At the time of transfer to another provider, did your agency provide the patient's current reconciled medication list to the subsequent provider?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - Current reconciled medication list not provided to the subsequent provider"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Current reconciled medication list provided to the subsequent provider"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"NA - The agency was not made aware of this transfer timely"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2121","prefix":"A2121","readOnly":false,"text":"Provision of Current Reconciled Medication List to Subsequent Provider at Discharge. At the time of discharge to another provider, did your agency provide the patient's current reconciled medication list to the subsequent provider?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - Current reconciled medication list not provided to the subsequent provider"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Current reconciled medication list provided to the subsequent provider"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2122","prefix":"A2122","readOnly":false,"text":"Route of Current Reconciled Medication List Transmission to Subsequent Provider. ","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Electronic Health Record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Health Information Exchange"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Verbal (e.g., in-person, telephone, video conferencing)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Paper-based (e.g., fax, copies, printouts)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Other Methods (e.g., texting, email, CDs)"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2123","prefix":"A2123","readOnly":false,"text":"Provision of Current Reconciled Medication List to Patient at Discharge. At the time of discharge, did your facility provide the patient's current reconciled medication list to the patient, family and/or caregiver?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - Current reconciled medication list not provided to the {patient/resident/person}, family and/or caregiver"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Current reconciled medication list provided to the {patient/resident/person}, family and/or caregiver"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2124","prefix":"A2124","readOnly":false,"text":"Route of Current Reconciled Medication List Transmission to Patient. Indicate the route(s) of transmission of the current reconciled medication list to the patient/family/caregiver.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Electronic Health Record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Health Information Exchange"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Verbal (e.g., in-person, telephone, video conferencing)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Paper-based (e.g., fax, copies, printouts)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Other Methods (e.g., texting, email, CDs)"}}]},{"repeats":false,"linkId":"Section B. Hearing, Speech, and Vision /B0200","prefix":"B0200","readOnly":false,"text":"Hearing. Ability to hear (with hearing aid or hearing appliances if normally used)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Adequate - no difficulty in normal conversation, social interaction, listening to TV"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Moderate difficulty - speaker has to increase volume and speak distinctly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Highly impaired - absence of useful hearing"}}]},{"repeats":false,"linkId":"Section B. Hearing, Speech, and Vision /B1000","prefix":"B1000","readOnly":false,"text":"Vision. Ability to see in adequate light (with glasses or other visual appliances)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Adequate - sees fine detail, such as regular print in newspapers/books"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Impaired - sees large print, but not regular print in newspapers/books"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Highly impaired - object identification in question, but eyes appear to follow objects"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects"}}]},{"repeats":false,"linkId":"Section B. Hearing, Speech, and Vision /B1300","prefix":"B1300","readOnly":false,"text":"Health Literacy. How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Often"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always"}},{"valueCoding":{"system":"http://del.cms.gov","code":"7","display":"{Patient/Resident/Person} declines to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"{Patient/Resident/Person} unable to respond"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0100","prefix":"C0100","readOnly":false,"text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all patients","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident/person} is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0200","prefix":"C0200","readOnly":false,"text":"Repetition of Three Words - Ask patient: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0300","prefix":"C0300","readOnly":false,"text":"Temporal Orientation (orientation to year, month, and day)","type":"question"},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0300A","prefix":"C0300A","readOnly":false,"text":"Ask patient: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0300B","prefix":"C0300B","readOnly":false,"text":"Ask patient: \"What month are we in right now?\" Able to report correct month","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0300C","prefix":"C0300C","readOnly":false,"text":"Ask patient: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0400","prefix":"C0400","readOnly":false,"text":"Recall. Ask patient: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"question"},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0400A","prefix":"C0400A","readOnly":false,"text":"Able to recall \"sock\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0400B","prefix":"C0400B","readOnly":false,"text":"Able to recall \"blue\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0400C","prefix":"C0400C","readOnly":false,"text":"Able to recall \"bed\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0500","prefix":"C0500","readOnly":false,"text":"BIMS Summary Score. Add scores for C0200-C0400 and fill in total score (00-15). Enter 99 if the patient was unable to complete the interview","type":"integer"},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310","prefix":"C1310","readOnly":false,"text":"Signs and Symptoms of Delirium (from CAM©)","type":"question"},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310A","prefix":"C1310A","readOnly":false,"text":"Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the patient's baseline?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310B","prefix":"C1310B","readOnly":false,"text":"Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Behavior not present"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Behavior continuously present, does not fluctuate"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Behavior present, fluctuates (comes and goes, changes in severity)"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310C","prefix":"C1310C","readOnly":false,"text":"Disorganized Thinking - Was the patient's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Behavior not present"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Behavior continuously present, does not fluctuate"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Behavior present, fluctuates (comes and goes, changes in severity)"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310D","prefix":"C1310D","readOnly":false,"text":"Altered Level of Consciousness - Did the patient have altered level of consciousness, as indicated by any of the following criteria? vigilant - startled easily to any sound or touch, lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch, stuporous - very difficult to arouse and keep aroused for the interview, comatose - could not be aroused","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Behavior not present"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Behavior continuously present, does not fluctuate"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Behavior present, fluctuates (comes and goes, changes in severity)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150","prefix":"D0150","readOnly":false,"text":"Patient Mood Interview (PHQ-2 to 9). Say to patient: \"Over the last 2 weeks, have you been bothered by any of the following problems?\"","type":"question"},{"repeats":false,"linkId":"Section D. Mood /D0150_1","prefix":"D0150_1","readOnly":false,"text":"Symptom Presence","type":"question"},{"repeats":false,"linkId":"Section D. Mood /D0150_2","prefix":"D0150_2","readOnly":false,"text":"Symptom Frequency","type":"question"},{"repeats":false,"linkId":"Section D. Mood /D0150A1","prefix":"D0150A1","readOnly":false,"text":"Little interest or pleasure in doing things - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150A2","prefix":"D0150A2","readOnly":false,"text":"Little interest of pleasure in doing things - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150B1","prefix":"D0150B1","readOnly":false,"text":"Feeling down, depressed, or hopeless - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150B2","prefix":"D0150B2","readOnly":false,"text":"Feeling down, depressed, or hopeless - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150C1","prefix":"D0150C1","readOnly":false,"text":"Trouble falling or staying asleep, or sleeping too much - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150C2","prefix":"D0150C2","readOnly":false,"text":"Trouble falling or staying asleep, or sleeping too much - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150D1","prefix":"D0150D1","readOnly":false,"text":"Feeling tired or having little energy - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150D2","prefix":"D0150D2","readOnly":false,"text":"Feeling tired or having little energy - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150E1","prefix":"D0150E1","readOnly":false,"text":"Poor appetite or overeating - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150E2","prefix":"D0150E2","readOnly":false,"text":"Poor appetite or overeating - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150F1","prefix":"D0150F1","readOnly":false,"text":"Feeling bad about yourself - or that you are a failure or have let yourself or your family down - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150F2","prefix":"D0150F2","readOnly":false,"text":"Feeling bad about yourself - or that you are a failure or have let yourself or your family down - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150G1","prefix":"D0150G1","readOnly":false,"text":"Trouble concentrating on things, such as reading the newspaper or watching television - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150G2","prefix":"D0150G2","readOnly":false,"text":"Trouble concentrating on things, such as reading the newspaper or watching television - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150H1","prefix":"D0150H1","readOnly":false,"text":"Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150H2","prefix":"D0150H2","readOnly":false,"text":"Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150I1","prefix":"D0150I1","readOnly":false,"text":"Thoughts that you would be better off dead, or of hurting yourself in some way - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150I2","prefix":"D0150I2","readOnly":false,"text":"Thoughts that you would be better off dead, or of hurting yourself in some way - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0160","prefix":"D0160","readOnly":false,"text":"Total Severity Score","type":"integer"},{"repeats":false,"linkId":"Section D. Mood /D0700","prefix":"D0700","readOnly":false,"text":"Social Isolation. How often do you feel lonely or isolated from those around you?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Often"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always"}},{"valueCoding":{"system":"http://del.cms.gov","code":"7","display":"{Patient/Resident/Person} declines to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"{Patient/Resident/Person} unable to respond"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100","prefix":"GG0100","readOnly":false,"text":"Prior Functioning: Everyday Activities. Indicate the patient's usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100A","prefix":"GG0100A","readOnly":false,"text":"Self-Care: Code the patient's need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident/Person} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident/Person} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100B","prefix":"GG0100B","readOnly":false,"text":"Indoor Mobility (Ambulation): Code the patient's need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident/Person} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident/Person} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100C","prefix":"GG0100C","readOnly":false,"text":"Stairs: Code the patient's need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident/Person} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident/Person} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100D","prefix":"GG0100D","readOnly":false,"text":"Functional Cognition: Code the patient's need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident/Person} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident/Person} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0110","prefix":"GG0110","readOnly":false,"text":"Prior Device Use. Indicate devices and aids used by the patient prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130","prefix":"GG0130","readOnly":false,"text":"Self-Care","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130_1","prefix":"GG0130_1","readOnly":false,"text":"Self-Care. Code the patient's usual performance at SOC/ROC for each activity using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130_2","prefix":"GG0130_2","readOnly":false,"text":"Self-Care. Code the patient's discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s).","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130_3","prefix":"GG0130_3","readOnly":false,"text":"Self-Care. Code the patient's usual performance at discharge for each activity using the 6-point scale. If any activity was not attempted at discharge, code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130_4","prefix":"GG0130_4","readOnly":false,"text":"Self-Care. Code the patient's usual performance at Follow-Up for each activity using the 6-point scale. If activity was not attempted at Follow-Up code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130A1","prefix":"GG0130A1","readOnly":false,"text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130A2","prefix":"GG0130A2","readOnly":false,"text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130A3","prefix":"GG0130A3","readOnly":false,"text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130A4","prefix":"GG0130A4","readOnly":false,"text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. - Follow-up Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130B1","prefix":"GG0130B1","readOnly":false,"text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130B2","prefix":"GG0130B2","readOnly":false,"text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130B3","prefix":"GG0130B3","readOnly":false,"text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130B4","prefix":"GG0130B4","readOnly":false,"text":"Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Follow-up Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130C1","prefix":"GG0130C1","readOnly":false,"text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. 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Functional Abilities and Goals/GG0130E1","prefix":"GG0130E1","readOnly":false,"text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. 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Functional Abilities and Goals/GG0130E2","prefix":"GG0130E2","readOnly":false,"text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130E3","prefix":"GG0130E3","readOnly":false,"text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130E4","prefix":"GG0130E4","readOnly":false,"text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130F1","prefix":"GG0130F1","readOnly":false,"text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130F2","prefix":"GG0130F2","readOnly":false,"text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130F3","prefix":"GG0130F3","readOnly":false,"text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130F4","prefix":"GG0130F4","readOnly":false,"text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130G1","prefix":"GG0130G1","readOnly":false,"text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130G2","prefix":"GG0130G2","readOnly":false,"text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130G3","prefix":"GG0130G3","readOnly":false,"text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130G4","prefix":"GG0130G4","readOnly":false,"text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130H1","prefix":"GG0130H1","readOnly":false,"text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130H2","prefix":"GG0130H2","readOnly":false,"text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130H3","prefix":"GG0130H3","readOnly":false,"text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130H4","prefix":"GG0130H4","readOnly":false,"text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170","prefix":"GG0170","readOnly":false,"text":"Mobility","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170_1","prefix":"GG0170_1","readOnly":false,"text":"Mobility. Code the patient's usual performance at SOC/ROC for each activity using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170_2","prefix":"GG0170_2","readOnly":false,"text":"Mobility. Code the patient's discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s).","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170_3","prefix":"GG0170_3","readOnly":false,"text":"Mobility. Code the patient's usual performance at discharge for each activity using the 6-point scale. If an activity was not attempted at discharge, code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170_4","prefix":"GG0170_4","readOnly":false,"text":"Mobility. Code the patient's usual performance at Follow-up for each activity using the 6-point scale. If activity was not attempted at Follow-up code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170A1","prefix":"GG0170A1","readOnly":false,"text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170A2","prefix":"GG0170A2","readOnly":false,"text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170A3","prefix":"GG0170A3","readOnly":false,"text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170A4","prefix":"GG0170A4","readOnly":false,"text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Follow-up Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170B1","prefix":"GG0170B1","readOnly":false,"text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. 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Functional Abilities and Goals/GG0170R1","prefix":"GG0170R1","readOnly":false,"text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170R2","prefix":"GG0170R2","readOnly":false,"text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170R3","prefix":"GG0170R3","readOnly":false,"text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170R4","prefix":"GG0170R4","readOnly":false,"text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Follow-up Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170RR1","prefix":"GG0170RR1","readOnly":false,"text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170RR3","prefix":"GG0170RR3","readOnly":false,"text":"Indicate the type of wheelchair or scooter used. - Discharge","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170S1","prefix":"GG0170S1","readOnly":false,"text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170S2","prefix":"GG0170S2","readOnly":false,"text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170S3","prefix":"GG0170S3","readOnly":false,"text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170SS1","prefix":"GG0170SS1","readOnly":false,"text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170SS3","prefix":"GG0170SS3","readOnly":false,"text":"Indicate the type of wheelchair or scooter used. - Discharge","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J0510","prefix":"J0510","readOnly":false,"text":"Pain Effect on Sleep. Ask patient: \"Over the past 5 days, how much of the time has pain made it hard for you to sleep at night?\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Does not apply - I have not had any pain or hurting in the past 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely or not at all"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Occasionally"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Frequently"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Almost constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unable to answer"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J0520","prefix":"J0520","readOnly":false,"text":"Pain Interference with Therapy Activities. Ask patient: \"Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain?\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Does not apply - I have not received rehabilitation therapy in the past 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely or not at all"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Occasionally"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Frequently"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Almost constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unable to answer"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J0530","prefix":"J0530","readOnly":false,"text":"Pain Interference with Day-to-Day Activities. Ask patient: \"Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain?\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely or not at all"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Occasionally"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Frequently"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Almost constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unable to answer"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J1800","prefix":"J1800","readOnly":false,"text":"Has the patient had any falls since SOC/ROC, whichever is more recent?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J1900","prefix":"J1900","readOnly":false,"text":"Number of Falls Since SOC/ROC, whichever is most recent","type":"question"},{"repeats":false,"linkId":"Section J. Health Conditions/J1900A","prefix":"J1900A","readOnly":false,"text":"No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two or more"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J1900B","prefix":"J1900B","readOnly":false,"text":"Injury (except major): skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two or more"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J1900C","prefix":"J1900C","readOnly":false,"text":"Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two or more"}}]},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/K0520","prefix":"K0520","readOnly":false,"text":"Nutritional Approaches","type":"question"},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/K0520_1","prefix":"K0520_1","readOnly":false,"text":"Check all of the following nutritional approaches that apply on {admission}","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Parenteral/IV feeding"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Feeding tube (e.g., nasogastric or abdominal (PEG))"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Therapeutic diet (e.g., low salt, diabetic, low cholesterol)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/K0520_4","prefix":"K0520_4","readOnly":false,"text":"Check all of the nutritional approaches that were received in the last 7 days","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Parenteral/IV feeding"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Feeding tube (e.g., nasogastric or abdominal (PEG))"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Therapeutic diet (e.g., low salt, diabetic, low cholesterol)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section K. 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Active Diagnoses/M1023_E2_ICD","prefix":"M1023_E2_ICD","readOnly":false,"text":"Other Diagnosis e.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (no diagnosis code)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"ICD","display":"ICD-10 diagnosis code"}}]},{"repeats":false,"linkId":"Section I. Active Diagnoses/M1023_E2_SEV","prefix":"M1023_E2_SEV","readOnly":false,"text":"Symptom Control Rating e.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"No severity rating"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Asymptomatic, no treatment needed at this time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Symptoms well controlled with current therapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Symptoms controlled with difficulty, affecting daily functioning; {patient/resident/person} needs ongoing monitoring"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Symptoms poorly controlled: {patient/resident/person} needs frequent adjustment in treatment and dose monitoring"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Symptoms poorly controlled: history of re-hospitalizations"}}]},{"repeats":false,"linkId":"Section I. Active Diagnoses/M1023_F2_ICD","prefix":"M1023_F2_ICD","readOnly":false,"text":"Other Diagnosis f.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (no diagnosis code)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"ICD","display":"ICD-10 diagnosis code"}}]},{"repeats":false,"linkId":"Section I. Active Diagnoses/M1023_F2_SEV","prefix":"M1023_F2_SEV","readOnly":false,"text":"Symptom Control Rating f.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"No severity rating"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Asymptomatic, no treatment needed at this time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Symptoms well controlled with current therapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Symptoms controlled with difficulty, affecting daily functioning; {patient/resident/person} needs ongoing monitoring"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Symptoms poorly controlled: {patient/resident/person} needs frequent adjustment in treatment and dose monitoring"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Symptoms poorly controlled: history of re-hospitalizations"}}]},{"repeats":false,"linkId":"Section I. Active Diagnoses/M1028","prefix":"M1028","readOnly":false,"text":"Active Diagnoses - Comorbidities and Co-existing Conditions: Check all that apply. See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Diabetes Mellitus (DM)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"None of the above"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/M1033","prefix":"M1033","readOnly":false,"text":"Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? Check all that apply","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"History of falls (2 or more falls - or any fall with an injury - in the past 12 months)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unintentional weight loss of a total of 10 pounds or more in the past 12 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Multiple hospitalizations (2 or more) in the past 6 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Multiple emergency department visits (2 or more) in the past 6 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Decline in mental, emotional, or behavioral status in the past 3 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"Currently taking 5 or more medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"Currently reports exhaustion"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Other risk(s) not listed in 1 - 8"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"None of the above"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/M1041","prefix":"M1041","readOnly":false,"text":"Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/M1046","prefix":"M1046","readOnly":false,"text":"Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year's flu season?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Yes; received from another health care provider (for example, physician, pharmacist)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"No; {patient/resident/person} offered and declined"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No; {patient/resident/person} assessed and determined to have medical contraindication(s)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"No; not indicated - {patient/resident/person} does not meet age/condition guidelines for influenza vaccine"}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"No; inability to obtain vaccine due to declared shortage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"No; {patient/resident/person} did not receive the vaccine due to reasons other than those listed in responses 4 - 7"}}]},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/M1060","prefix":"M1060","readOnly":false,"text":"Height and Weight. While measuring, if the number is X.1-X.4 round down, X.5 or greater round up","type":"question"},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/M1060_A","prefix":"M1060_A","readOnly":false,"text":"Height (in inches). Record most recent height measure since the most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/M1060_B","prefix":"M1060_B","readOnly":false,"text":"Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to standard agency practice (for example, in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer"},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M1100","prefix":"M1100","readOnly":false,"text":"Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only.)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident/Person} lives alone, around the clock assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident/Person} lives alone, regular daytime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} lives alone, regular nighttime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident/Person} lives alone, occasional / short-term assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident/Person} lives alone, no assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"{Patient/Resident/Person} lives with other person(s) in the home, around the clock assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} lives with other person(s) in the home, regular daytime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"{Patient/Resident/Person} lives with other person(s) in the home, regular nighttime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"{Patient/Resident/Person} lives with other person(s) in the home, occasional/short-term assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"{Patient/Resident/Person} lives with other person(s) in the home, no assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), around the clock assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"12","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), regular daytime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"13","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), regular nighttime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"14","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), occasional / short-term assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"15","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), no assistance available."}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1306","prefix":"M1306","readOnly":false,"text":"Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? (Excludes Stage 1 pressure injuries and all healed pressure ulcers/injuries)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1307","prefix":"M1307","readOnly":false,"text":"The Oldest Stage 2 Pressure Ulcer that is present at discharge: (Excludes healed Stage 2 Pressure Ulcers)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Was present at the most recent SOC/ROC assessment"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Developed since the most recent SOC/ROC assessment"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"No Stage 2 pressure ulcers are present at discharge"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1307_DT","prefix":"M1307_DT","readOnly":false,"text":"Record date pressure ulcer first identified","type":"date"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311","prefix":"M1311","readOnly":false,"text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Admission","type":"question"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_A1","prefix":"M1311_A1","readOnly":false,"text":"Number of Stage 2 pressure ulcers","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_A2","prefix":"M1311_A2","readOnly":false,"text":"Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_B1","prefix":"M1311_B1","readOnly":false,"text":"Number of Stage 3 pressure ulcers","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_B2","prefix":"M1311_B2","readOnly":false,"text":"Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_C1","prefix":"M1311_C1","readOnly":false,"text":"Number of Stage 4 pressure ulcers","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_C2","prefix":"M1311_C2","readOnly":false,"text":"Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_D1","prefix":"M1311_D1","readOnly":false,"text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_D2","prefix":"M1311_D2","readOnly":false,"text":"Number of these unstageable pressure ulcers/injuries that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_E1","prefix":"M1311_E1","readOnly":false,"text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_E2","prefix":"M1311_E2","readOnly":false,"text":"Number of these unstageable pressure ulcers that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_F1","prefix":"M1311_F1","readOnly":false,"text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_F2","prefix":"M1311_F2","readOnly":false,"text":"Number of these unstageable pressure injuries that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1322","prefix":"M1322","readOnly":false,"text":"Current Number of Stage 1 Pressure Injuries. Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"0"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"1"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"2"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"3"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"4 or more"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1324","prefix":"M1324","readOnly":false,"text":"Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable. Excludes pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar, or deep tissue injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Stage 1"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Stage 2"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Stage 3"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Stage 4"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} has no pressure ulcers/injuries or no stageable pressure ulcers/injuries"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1330","prefix":"M1330","readOnly":false,"text":"Does this patient have a Stasis Ulcer?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes, {patient/resident/person} has BOTH observable and unobservable stasis ulcers."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Yes, {patient/resident/person} has observable stasis ulcers ONLY."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Yes, {patient/resident/person} has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing/device)"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1332","prefix":"M1332","readOnly":false,"text":"Current Number of Stasis Ulcer(s) that are Observable","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Four or more"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1334","prefix":"M1334","readOnly":false,"text":"Status of Most Problematic Stasis Ulcer that is Observable","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Fully granulating"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Early/partial granulation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Not healing"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1340","prefix":"M1340","readOnly":false,"text":"Does this patient have a Surgical Wound?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes, {patient/resident/person} has at least one observable surgical wound"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Surgical wound known but not observable due to non-removable dressing/device"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1342","prefix":"M1342","readOnly":false,"text":"Status of Most Problematic Surgical Wound that is Observable","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Newly epithelialized"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Fully granulating"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Early/partial granulation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Not healing"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/M1400","prefix":"M1400","readOnly":false,"text":"When is the patient dyspneic or noticeably Short of Breath?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"{Patient/Resident/Person} is not short of breath"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"When walking more than 20 feet, climbing stairs"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"With moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than 20 feet)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"With minimal exertion (for example, while eating, talking, or performing other ADLs) or with agitation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"At rest (during day or night)"}}]},{"repeats":false,"linkId":"Section H. Bladder and Bowel/M1600","prefix":"M1600","readOnly":false,"text":"Has this patient been treated for a Urinary Tract Infection in the past 14 days?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} on prophylactic treatment"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Unknown"}}]},{"repeats":false,"linkId":"Section H. Bladder and Bowel/M1610","prefix":"M1610","readOnly":false,"text":"Urinary Incontinence or Urinary Catheter Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No incontinence or catheter (includes anuria or ostomy for urinary drainage)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident/Person} is incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident/Person} requires a urinary catheter (specifically: external, indwelling, intermittent, or suprapubic)"}}]},{"repeats":false,"linkId":"Section H. Bladder and Bowel/M1620","prefix":"M1620","readOnly":false,"text":"Bowel Incontinence Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Very rarely or never has bowel incontinence"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Less than once weekly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"One to three times weekly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Four to six times weekly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"On a daily basis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"More often than once daily"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} has ostomy for bowel elimination"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Unknown"}}]},{"repeats":false,"linkId":"Section H. Bladder and Bowel/M1630","prefix":"M1630","readOnly":false,"text":"Ostomy for Bowel Elimination. Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay; or b) necessitated a change in medical or treatment regimen?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"{Patient/Resident/Person} does not have an ostomy for bowel elimination."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient's/Resident's} ostomy was not related to an inpatient stay and did not necessitate change in medical or treatment regimen."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"The ostomy was related to an inpatient stay or did necessitate change in medical or treatment regimen."}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /M1700","prefix":"M1700","readOnly":false,"text":"Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Requires assistance and some direction in specific situations (for example, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Requires considerable assistance in routine situations. Is not alert and oriented or is unable to shift attention and recall directions more than half the time."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium."}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /M1710","prefix":"M1710","readOnly":false,"text":"When Confused. Reported or Observed Within the Last 14 Days.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Never"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"In new or complex situations only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"On awakening or at night only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"During the day and evening, but not constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} nonresponsive"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /M1720","prefix":"M1720","readOnly":false,"text":"When Anxious. Reported or Observed Within the Last 14 Days.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"None of the time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Less often than daily"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Daily, but not constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"All of the time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} nonresponsive"}}]},{"repeats":false,"linkId":"Section E. Behavior /M1740","prefix":"M1740","readOnly":false,"text":"Cognitive, Behavioral, and Psychiatric symptoms that are demonstrated at least once a week (Reported or Observed). Check all that apply","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Memory deficit: failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Verbal disruption: yelling, threatening, excessive profanity, sexual references, etc."}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Physical aggression: aggressive or combative to self and others (for example, hits self, throws objects, punches, dangerous maneuvers with wheelchair or other objects)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Disruptive, infantile, or socially inappropriate behavior (excludes verbal actions)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"6","display":"Delusional, hallucinatory, or paranoid behavior"}},{"valueCoding":{"system":"http://del.cms.gov","code":"7","display":"None of the above behaviors demonstrated"}}]},{"repeats":false,"linkId":"Section E. Behavior /M1745","prefix":"M1745","readOnly":false,"text":"Frequency of Disruptive Behavior Symptoms (Reported or Observed). Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Never"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Less than once a month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Once a month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Several times each month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Several times a week"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"At least daily"}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1800","prefix":"M1800","readOnly":false,"text":"Grooming. Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care).","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to groom self unaided, with or without the use of assistive devices or adapted methods."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Grooming utensils must be placed within reach before able to complete grooming activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Someone must assist the {patient/resident/person} to groom self."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} depends entirely upon someone else for grooming needs."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1810","prefix":"M1810","readOnly":false,"text":"Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons and snaps.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to dress upper body without assistance if clothing is laid out or handed to the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Someone must help the {patient/resident/person} put on upper body clothing."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} depends entirely upon another person to dress the upper body."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1820","prefix":"M1820","readOnly":false,"text":"Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to obtain, put on, and remove clothing and shoes without assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to dress lower body without assistance if clothing and shoes are laid out or handed to the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Someone must help the {patient/resident/person} put on undergarments, slacks, socks or nylons, and shoes."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} depends entirely upon another person to dress lower body."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1830","prefix":"M1830","readOnly":false,"text":"Bathing. Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to bathe self in shower or tub independently, including getting in and out of tub/shower."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of the tub/shower."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Unable to participate effectively in bathing and is bathed totally by another person."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1840","prefix":"M1840","readOnly":false,"text":"Toilet Transferring. Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to get to and from the toilet and transfer independently with or without a device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Is totally dependent in toileting."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1845","prefix":"M1845","readOnly":false,"text":"Toileting Hygiene. Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to manage toileting hygiene and clothing management without assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Someone must help the {patient/resident/person} to maintain toileting hygiene and/or adjust clothing."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} depends entirely upon another person to maintain toileting hygiene."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1850","prefix":"M1850","readOnly":false,"text":"Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently transfer."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to transfer with minimal human assistance or with use of an assistive device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Able to bear weight and pivot during the transfer process but unable to transfer self."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Unable to transfer self and is unable to bear weight or pivot when transferred by another person."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Bedfast, unable to transfer but is able to turn and position self in bed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Bedfast, unable to transfer and is unable to turn and position self."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1860","prefix":"M1860","readOnly":false,"text":"Ambulation/Locomotion. Current ability to walk safely, once in a standing position, or use a wheelchair, once in in a seated position, on a variety of surfaces.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (specifically: needs no human assistance or assistive device)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Requires use of a two-handed device (for example, walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Able to walk only with the supervision or assistance of another person at all times."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Chairfast, unable to ambulate but is able to wheel self independently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Chairfast, unable to ambulate and is unable to wheel self."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Bedfast, unable to ambulate or be up in a chair."}}]},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/M1870","prefix":"M1870","readOnly":false,"text":"Feeding or Eating. Current ability to feed self meals and snacks safely. Note: This refers only to the process of eating, chewing, and swallowing, not preparing the food to be eaten.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently feed self."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to feed self independently but requires: (a) meal set-up; OR (b) intermittent assistance or supervision from another person; OR (c) a liquid, pureed or ground meat diet."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unable to feed self and must be assisted or supervised throughout the meal/snack."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Able to take in nutrients orally and receives supplemental nutrients though a nasogastric tube or gastrostomy."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Unable to take in nutrients orally or by tube feeding."}}]},{"repeats":false,"linkId":"Section N. Medications /M2001","prefix":"M2001","readOnly":false,"text":"Drug Regimen Review. Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident/Person} is not taking any medications"}}]},{"repeats":false,"linkId":"Section N. Medications /M2003","prefix":"M2003","readOnly":false,"text":"Medication Follow-up. Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section N. Medications /M2005","prefix":"M2005","readOnly":false,"text":"Medication Intervention. Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - There were no potential clinically significant medication issues identified since {admission} or {patient/resident/person} is not taking any medications"}}]},{"repeats":false,"linkId":"Section N. Medications /M2010","prefix":"M2010","readOnly":false,"text":"Patient/Caregiver High-Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} not taking any high-risk drugs OR {patient/resident/person}/caregiver fully knowledgeable about special precautions associated with all high-risk medications"}}]},{"repeats":false,"linkId":"Section N. Medications /M2016","prefix":"M2016","readOnly":false,"text":"Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} not taking any drugs"}}]},{"repeats":false,"linkId":"Section N. Medications /M2020","prefix":"M2020","readOnly":false,"text":"Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. Excludes injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness.)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Able to take medication(s) at the correct times if given reminders by another person at the appropriate times"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Unable to take medication unless administered by another person."}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"No oral medications prescribed."}}]},{"repeats":false,"linkId":"Section N. Medications /M2030","prefix":"M2030","readOnly":false,"text":"Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. Excludes IV medications.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently take the correct medication(s) and proper dosage(s) at the correct times."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Unable to take injectable medication unless administered by another person."}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"No injectable medications prescribed."}}]},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102","prefix":"M2102","readOnly":false,"text":"Types and Sources of Assistance. Determine the ability and willingness of non-agency caregivers (such as family members, friends, or privately paid caregivers) to provide assistance for the following activities, if assistance is needed. Excludes all care by your agency staff.","type":"question"},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102_A","prefix":"M2102_A","readOnly":false,"text":"ADL assistance (for example, transfer/ambulation, bathing, dressing, toileting, eating/feeding)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No assistance needed - {patient/resident/person} is independent or does not have needs in this area"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Non-agency caregiver(s) currently provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Non-agency caregiver(s) need training/supportive services to provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Assistance needed, but no non-agency caregiver(s) available"}}]},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102_C","prefix":"M2102_C","readOnly":false,"text":"Medication administration (for example, oral, inhaled or injectable)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No assistance needed - {patient/resident/person} is independent or does not have needs in this area"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Non-agency caregiver(s) currently provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Non-agency caregiver(s) need training/supportive services to provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Assistance needed, but no non-agency caregiver(s) available"}}]},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102_D","prefix":"M2102_D","readOnly":false,"text":"Medical procedures/treatments (for example, changing wound dressing, home exercise program)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No assistance needed - {patient/resident/person} is independent or does not have needs in this area"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Non-agency caregiver(s) currently provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Non-agency caregiver(s) need training/supportive services to provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Assistance needed, but no non-agency caregiver(s) available"}}]},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102_F","prefix":"M2102_F","readOnly":false,"text":"Supervision and safety (for example, due to cognitive impairment)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No assistance needed - {patient/resident/person} is independent or does not have needs in this area"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Non-agency caregiver(s) currently provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Non-agency caregiver(s) need training/supportive services to provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Assistance needed, but no non-agency caregiver(s) available"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/M2200","prefix":"M2200","readOnly":false,"text":"Therapy Need. In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits (total of reasonable and necessary physical, occupational, and speech-language pathology visits combined)? Enter zero [\"000\"] if no therapy visits indicated.","type":"integer"},{"repeats":false,"linkId":"Section A. Administrative Information /M2301","prefix":"M2301","readOnly":false,"text":"Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes, used hospital emergency department WITHOUT hospital admission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Yes, used hospital emergency department WITH hospital admission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Unknown"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /M2310","prefix":"M2310","readOnly":false,"text":"Reason for Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or without hospitalization)? (Check all that apply)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Improper medication administration, adverse drug reactions, medication side effects, toxicity, anaphylaxis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Hypo/Hyperglycemia, diabetes out of control"}},{"valueCoding":{"system":"http://del.cms.gov","code":"19","display":"Other than above reasons"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Reason unknown"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401","prefix":"M2401","readOnly":false,"text":"Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? (Check only one box in each row)","type":"question"},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_B","prefix":"M2401_B","readOnly":false,"text":"Falls prevention interventions","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_C","prefix":"M2401_C","readOnly":false,"text":"Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_D","prefix":"M2401_D","readOnly":false,"text":"Intervention(s) to monitor and mitigate pain","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_E","prefix":"M2401_E","readOnly":false,"text":"Intervention(s) to prevent pressure ulcers","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_F","prefix":"M2401_F","readOnly":false,"text":"Pressure ulcer treatment based on principles of moist wound healing","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /M2410","prefix":"M2410","readOnly":false,"text":"To which Inpatient Facility has the patient been admitted?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Rehabilitation facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Nursing home"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Hospice"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"No inpatient facility admission"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /M2420","prefix":"M2420","readOnly":false,"text":"Discharge Disposition: Where is the patient after discharge from your agency? Choose only one answer","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident/Person} remained in the community (without formal assistive services)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident/Person} remained in the community (with formal assistive services)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} transferred to a non-institutional hospice"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unknown because {patient/resident/person} moved to a geographic location not served by this agency"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Other unknown"}}]},{"repeats":false,"linkId":"Section N. Medications /N0415","prefix":"N0415","readOnly":false,"text":"High-Risk Drug Classes: Use and Indication","type":"question"},{"repeats":false,"linkId":"Section N. Medications /N0415_1","prefix":"N0415_1","readOnly":false,"text":"Check if the patient is taking any medications by pharmacological classification, not how it is used, in the following classes","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Antipsychotic"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Anticoagulant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Antibiotic"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Opioid"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Antiplatelet"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Hypoglycemic (including insulin)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section N. Medications /N0415_2","prefix":"N0415_2","readOnly":false,"text":"High-Risk Drug Classes: Use and Indication - Indication noted","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Antipsychotic"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Anticoagulant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Antibiotic"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Opioid"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Antiplatelet"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Hypoglycemic (including insulin)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/O0110","prefix":"O0110","readOnly":false,"text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that apply.","type":"question"},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/O0110_a","prefix":"O0110_a","readOnly":false,"text":"Special Treatments, Procedures, and Programs - On Admission","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A1","display":"Chemotherapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A10","display":"Chemotherapy - Other"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A2","display":"Chemotherapy - IV"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A3","display":"Chemotherapy - Oral"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B1","display":"Radiation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C1","display":"Oxygen Therapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C2","display":"Oxygen Therapy - Continuous"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C3","display":"Oxygen Therapy - Intermittent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C4","display":"Oxygen Therapy - High-concentration"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D1","display":"Suctioning"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D2","display":"Suctioning - Scheduled"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D3","display":"Suctioning - As Needed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E1","display":"Tracheostomy care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F1","display":"Invasive Mechanical Ventilator (ventilator or respirator)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G1","display":"Non-Invasive Mechanical Ventilator"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G2","display":"Non-Invasive Mechanical Ventilator - BiPAP"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G3","display":"Non-Invasive Mechanical Ventilator - CPAP"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H1","display":"IV Medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H10","display":"IV Medications - Other"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H2","display":"IV Medications - Vasoactive medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H3","display":"IV Medications - Antibiotics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H4","display":"IV Medications - Anticoagulant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1","display":"Transfusions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J1","display":"Dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J2","display":"Dialysis - Hemodialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J3","display":"Dialysis - Peritoneal dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O1","display":"IV Access"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O2","display":"IV Access - Peripheral"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O3","display":"IV Access - Midline"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O4","display":"IV Access - Central (e.g., PICC, tunneled, port)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z1","display":"None of the Above"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/O0110_c","prefix":"O0110_c","readOnly":false,"text":"Special Treatments, Procedures, and Programs - At Discharge","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A1","display":"Chemotherapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A10","display":"Chemotherapy - Other"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A2","display":"Chemotherapy - IV"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A3","display":"Chemotherapy - Oral"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B1","display":"Radiation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C1","display":"Oxygen Therapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C2","display":"Oxygen Therapy - Continuous"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C3","display":"Oxygen Therapy - Intermittent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C4","display":"Oxygen Therapy - High-concentration"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D1","display":"Suctioning"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D2","display":"Suctioning - Scheduled"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D3","display":"Suctioning - As Needed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E1","display":"Tracheostomy care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F1","display":"Invasive Mechanical Ventilator (ventilator or respirator)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G1","display":"Non-Invasive Mechanical Ventilator"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G2","display":"Non-Invasive Mechanical Ventilator - BiPAP"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G3","display":"Non-Invasive Mechanical Ventilator - CPAP"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H1","display":"IV Medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H10","display":"IV Medications - Other"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H2","display":"IV Medications - Vasoactive medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H3","display":"IV Medications - Antibiotics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H4","display":"IV Medications - Anticoagulant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1","display":"Transfusions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J1","display":"Dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J2","display":"Dialysis - Hemodialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J3","display":"Dialysis - Peritoneal dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O1","display":"IV Access"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O2","display":"IV Access - Peripheral"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O3","display":"IV Access - Midline"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O4","display":"IV Access - Central (e.g., PICC, tunneled, port)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z1","display":"None of the Above"}}]}],"_id":"ipoSii7W9s43qBcbN"} {"responseType":"QuestionnaireResponse","questionnaire":"HIS-HA-2.00.0","id":"HIS-HA-2.00.0-1","title":"Hospice Item Set - Hospice Admission Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-09-20T06:29:57.933Z","item":[{"linkId":"Section-36","text":"Section A: Administrative Information","type":"group","readOnly":true,"item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0"},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3"},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5"},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Admitted From. Immediately preceding this admission, where was the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.6"},{"linkId":"Section-36/A0550","prefix":"A0550","text":"{Patient/Resident} ZIP Code.","type":"text","repeats":false,"readOnly":false,"maxLength":11,"id":"item.0.item.7"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1"}],"id":"item.0.item.8"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3"}],"id":"item.0.item.9"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1"}],"id":"item.0.item.10"},{"linkId":"Section-36/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.11"},{"linkId":"Section-36/A1400","prefix":"A1400","text":"Payer Information: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.12"},{"linkId":"Section-36/A0205","prefix":"A0205","text":"Site of Service at Admission","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.13"},{"linkId":"Section-36/A0245","prefix":"A0245","text":"Date Initial Nursing Assessment Initiated","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.14"}],"id":"item.0","description":"The patient must fill out Section A, which pertains to administrative information."},{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0","description":"The form asks the patient to enter their Medicaid number. If their Medicaid is still pending, they should enter \"+\". If they are not a Medicaid recipient, they should enter \"N\"."},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1","description":"What is the patient's gender? The options are male, female, or prefer not to say."},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2","description":"What is the patient's date of birth?"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3","description":"The type of record for the patient needs to be identified."},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4","description":"What is the reason for the patient's assessment?"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5","description":"What is the patient's admission date?"},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Admitted From. Immediately preceding this admission, where was the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.6","description":"Where was the patient immediately preceding this admission? Was the patient admitted from their home, another hospital, a nursing home, or somewhere else?"},{"linkId":"Section-36/A0550","prefix":"A0550","text":"{Patient/Resident} ZIP Code.","type":"text","repeats":false,"readOnly":false,"maxLength":11,"id":"item.0.item.7","description":"What is the patient's or resident's ZIP code?"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1"}],"id":"item.0.item.8","description":"The patient needs to provide the numbers associated with their facility provider."},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0","description":"What is the patient's National Provider Identifier (NPI)?"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1","description":"What is the patient's CMS Certification Number (CCN)?"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3"}],"id":"item.0.item.9","description":"What is the legal name of the patient or resident?"},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0","description":"What is the patient's first name?"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1","description":"What is the patient's middle initial?"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last 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the relevant options."},{"linkId":"Section-36/A0205","prefix":"A0205","text":"Site of Service at Admission","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.13","description":"What was the patient's site of service at the time of admission?"},{"linkId":"Section-36/A0245","prefix":"A0245","text":"Date Initial Nursing Assessment Initiated","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.14","description":"The date the initial nursing assessment for the patient was initiated."},{"linkId":"Section-47","text":"Section F: Preferences","type":"group","readOnly":true,"item":[{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0"},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1"}],"id":"item.1.item.0"},{"linkId":"Section-47/F2100","prefix":"F2100","text":"Other Life-Sustaining Treatment Preferences","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0"},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1"}],"id":"item.1.item.1"},{"linkId":"Section-47/F2200","prefix":"F2200","text":"Hospitalization Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0"},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1"}],"id":"item.1.item.2"},{"linkId":"Section-47/F3000","prefix":"F3000","text":"Spiritual/Existential Concerns","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0"},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1"}],"id":"item.1.item.3"}],"id":"item.1","description":"In section F of the form, the patient's preferences are discussed."},{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0"},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1"}],"id":"item.1.item.0","description":"Does the patient have a preference regarding CPR?"},{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0","description":"Was the patient, or the responsible party, asked about their preference regarding the use of cardiopulmonary resuscitation (CPR)? Please select the most accurate response."},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1","description":"The date when the patient or responsible party was first asked about their preference regarding the use of CPR."},{"linkId":"Section-47/F2100","prefix":"F2100","text":"Other Life-Sustaining Treatment Preferences","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0"},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1"}],"id":"item.1.item.1","description":"Does the patient have other life-sustaining treatment preferences?"},{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0","description":"Was the patient or responsible party asked about their preferences regarding life-sustaining treatments other than CPR? Please select the most accurate response."},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1","description":"The date on which the patient or responsible party was first asked about their preferences regarding life-sustaining treatments other than Cardiopulmonary Resuscitation was:"},{"linkId":"Section-47/F2200","prefix":"F2200","text":"Hospitalization Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0"},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1"}],"id":"item.1.item.2","description":"The patient has to choose their hospitalization preference."},{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0","description":"Was the patient or the responsible party asked about their preference regarding hospitalization? Please select the most accurate response."},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1","description":"The date that the patient, resident, or responsible party was first asked about their preference regarding hospitalization was:"},{"linkId":"Section-47/F3000","prefix":"F3000","text":"Spiritual/Existential Concerns","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0"},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1"}],"id":"item.1.item.3","description":"Does the patient have any spiritual or existential concerns?"},{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0","description":"Was the patient or resident and/or their caregiver asked about any spiritual or existential concerns? Please select the most accurate response."},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1","description":"When was the patient or their caregiver first asked about their spiritual or existential concerns?"},{"linkId":"Section-9","text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal Diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"}],"id":"item.2","description":"In Section I of the form, the patient's active diagnoses are listed."},{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal Diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"What is the patient's principal diagnosis?"},{"linkId":"Section-10","text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J0900","prefix":"J0900","text":"Pain Screening","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3"}],"id":"item.3.item.0"},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Pain Active Problem. Is pain an active problem for the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.1"},{"linkId":"Section-10/J0910","prefix":"J0910","text":"Comprehensive Pain Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2"}],"id":"item.3.item.2"},{"linkId":"Section-10/J2030","prefix":"J2030","text":"Screening for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2"}],"id":"item.3.item.3"},{"linkId":"Section-10/J2040","prefix":"J2040","text":"Treatment for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0"},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2"}],"id":"item.3.item.4"}],"id":"item.3","description":"In Section J of the form, the patient is asked about their health conditions."},{"linkId":"Section-10/J0900","prefix":"J0900","text":"Pain Screening","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3"}],"id":"item.3.item.0","description":"The patient is asked to participate in a pain screening."},{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0","description":"Was the patient or resident screened for pain?"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1","description":"When was the patient first screened for pain?"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2","description":"The severity of the patient's or resident's pain was:"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3","description":"The type of standardized pain tool used for the patient is:"},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Pain Active Problem. Is pain an active problem for the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.1","description":"Is pain an active problem for the patient or resident?"},{"linkId":"Section-10/J0910","prefix":"J0910","text":"Comprehensive Pain Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2"}],"id":"item.3.item.2","description":"The patient is required to fill out a comprehensive pain assessment."},{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0","description":"Was a comprehensive pain assessment conducted on the patient?"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1","description":"When was the date of the patient's comprehensive pain assessment?"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2","description":"The patient's form included a comprehensive pain assessment which stated: \"Check all that apply.\""},{"linkId":"Section-10/J2030","prefix":"J2030","text":"Screening for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2"}],"id":"item.3.item.3","description":"The patient is undergoing screening for shortness of breath."},{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0","description":"Was the patient or resident screened for symptoms of shortness of breath?"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1","description":"What was the date of the patient's first screening for shortness of breath?"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2","description":"Did the screening indicate that the patient had shortness of breath?"},{"linkId":"Section-10/J2040","prefix":"J2040","text":"Treatment for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0"},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2"}],"id":"item.3.item.4","description":"What is the patient's treatment for shortness of breath?"},{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0","description":"Was the treatment for the patient's shortness of breath initiated? Please select the most accurate response."},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1","description":"What is the date when the treatment for shortness of breath was initiated for the patient?"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2","description":"What types of treatment for shortness of breath has the patient initiated? Please check all that apply."},{"linkId":"Section-14","text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/N0500","prefix":"N0500","text":"Scheduled Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1"}],"id":"item.4.item.0"},{"linkId":"Section-14/N0510","prefix":"N0510","text":"PRN Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0"},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1"}],"id":"item.4.item.1"},{"linkId":"Section-14/N0520","prefix":"N0520","text":"Bowel Regimen - Complete only if {scheduled opioid or PRN opioid = yes}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0"},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1"}],"id":"item.4.item.2"}],"id":"item.4","description":"In Section N of the form, the patient is asked to provide information about their medications."},{"linkId":"Section-14/N0500","prefix":"N0500","text":"Scheduled Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1"}],"id":"item.4.item.0","description":"Does the patient have a scheduled opioid medication regimen?"},{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0","description":"Did the patient have a scheduled opioid initiated or continued?"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1","description":"The date the patient's opioid treatment was initiated or continued is scheduled for:"},{"linkId":"Section-14/N0510","prefix":"N0510","text":"PRN Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0"},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1"}],"id":"item.4.item.1","description":"Does the patient take opioid medication as needed?"},{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0","description":"Was a PRN opioid initiated or continued for the patient? The answer choices are: initiated, continued, or neither."},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1","description":"The date on which the patient's PRN opioid was initiated or continued."},{"linkId":"Section-14/N0520","prefix":"N0520","text":"Bowel Regimen - Complete only if {scheduled opioid or PRN opioid = yes}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0"},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1"}],"id":"item.4.item.2","description":"The patient should complete the section \"Bowel Regimen\" only if they are scheduled for opioid treatment or have been prescribed opioids on an as-needed basis."},{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0","description":"Was a bowel regimen initiated or continued for the patient? Please select the most accurate response."},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1","description":"The date when the patient's bowel regimen was initiated or continued is required."},{"linkId":"Section-50","text":"Section O: Service Utilization","type":"group","readOnly":true,"item":[{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.0"}],"id":"item.5","description":"In Section O of the form, the patient's service utilization is assessed."},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.0","description":"What was the level of care the patient received in the final 3 days?"},{"linkId":"Section-48","text":"Section Z: Record Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0"},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1"}],"id":"item.6","description":"In section Z of the form, the administration records pertaining to the patient are documented."},{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0","description":"The signature of the person who completed the patient's assessment is required."},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0","description":"The patient is required to provide their signature, title, and date they completed section A."},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1","description":"The patient needs to provide their Signature, Title, ensure all Sections are filled out, and include the Date the Section was completed B."},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2","description":"The patient needs to provide their signature, title, and complete the sections required on the form. They should also include the date the section was completed, indicated as section C."},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3","description":"The patient filled out the signature, title, and sections, and completed section D on a specific date."},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4","description":"The sections of the form labeled \"Signature\", \"Title\", and \"Date Section Completed E\" should be filled out by the patient."},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5","description":"The form for the patient includes sections for signature, title, and the date when the section was completed."},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6","description":"The patient's signature, title, and the date the section was completed are all required in Section G."},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7","description":"The patient is required to provide their signature and title in the designated sections, and also specify the date when the section was completed."},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8","description":"The patient needs to provide their signature, title, and the sections they have completed on the form, along with the date the section was finished."},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9","description":"The patient is required to provide their signature, title, and date for each completed section on the form."},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10","description":"The patient is required to provide their signature, title, and date on the sections they have completed in Section K."},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11","description":"The patient must provide their signature, title, and date in the sections indicated upon completion."},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1","description":"The signature of the RN Coordinator is required to verify the completion of the patient's assessment."},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0","description":"The form requires the patient's signature."},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1","description":"The date on which the Registered Nurse Assessment Coordinator signed the patient's assessment as complete."},null],"_id":"3GG8fQtzmGvRjwsde"} {"responseType":"QuestionnaireResponse","questionnaire":"HIS-HD-2.00.0","id":"HIS-HD-2.00.0-1","title":"Hospice Item Set - Hospice Discharge Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-09-20T06:33:39.936Z","item":[{"linkId":"Section-36","text":"Section A: Administrative Information","type":"group","readOnly":true,"item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0"},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3"},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5"},{"linkId":"Section-36/A0270","prefix":"A0270","text":"Discharge Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.6"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1"}],"id":"item.0.item.7"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3"}],"id":"item.0.item.8"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1"}],"id":"item.0.item.9"},{"linkId":"Section-36/A2115","prefix":"A2115","text":"Reason for Discharge","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.10"}],"id":"item.0","description":"The section A on the form is for administrative information about the patient."},{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0","description":"The form asks for the patient's Medicaid Number. They should enter \"+\" if their Medicaid application is pending, or \"N\" if they are not a Medicaid recipient."},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1","description":"What is the patient's gender?"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2","description":"What is the patient's birth date?"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3","description":"The type of record pertaining to the patient needs to be identified."},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4","description":"The reason for the patient's assessment should be clearly specified."},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5","description":"What is the patient's admission date?"},{"linkId":"Section-36/A0270","prefix":"A0270","text":"Discharge Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.6","description":"What is the patient's discharge date?"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1"}],"id":"item.0.item.7","description":"The facility has designated provider numbers for the patient."},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0","description":"What is the patient's National Provider Identifier (NPI)?"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1","description":"The patient needs to provide their CMS Certification Number (CCN)."},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3"}],"id":"item.0.item.8","description":"What is the legal name of the patient or resident?"},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0","description":"What is the patient's first name?"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1","description":"What is the patient's middle initial?"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2","description":"What is the patient's last name?"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3","description":"What is the patient's suffix?"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1"}],"id":"item.0.item.9","description":"The patient needs to provide their Social Security and Medicare numbers."},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0","description":"What is the patient's Social Security Number?"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1","description":"What is the patient's Medicare number?"},{"linkId":"Section-36/A2115","prefix":"A2115","text":"Reason for Discharge","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.10","description":"What is the reason for the patient's discharge?"},{"linkId":"Section-47","text":"Section F: Preferences","type":"group","readOnly":true,"item":[{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR preference","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.1.item.0"}],"id":"item.1","description":"In section F of the form, the patient's preferences are to be indicated."},{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR preference","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.1.item.0","description":"What is the patient's preference regarding CPR?"},{"linkId":"Section-9","text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"}],"id":"item.2","description":"In Section I of the form, the active diagnoses of the patient are listed."},{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"The principal diagnosis for the patient is still undetermined."},{"linkId":"Section-10","text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J0100","prefix":"J0100","text":"Pain Management","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.3.item.0"}],"id":"item.3","description":"In Section J of the form, the patient is asked to provide information about their health conditions."},{"linkId":"Section-10/J0100","prefix":"J0100","text":"Pain Management","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.3.item.0","description":"Does the patient require pain management?"},{"linkId":"Section-14","text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/M2003","prefix":"M2003","text":"Medication follow-up","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.4.item.0"}],"id":"item.4","description":"In Section N of the form, it asks about the patient's medications."},{"linkId":"Section-14/M2003","prefix":"M2003","text":"Medication follow-up","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.4.item.0","description":"Does the patient require a medication follow-up?"},{"linkId":"Section-50","text":"Section O: Service Utilization","type":"group","readOnly":true,"item":[{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.0"},{"linkId":"Section-50/O5010","prefix":"O5010","text":"Number of hospice visits in final 3 days. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0"},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1"},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2"}],"id":"item.5.item.1"},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Registered Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.2"},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"Registered Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.3"},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"Registered Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.4"},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.5"},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.6"},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.7"},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"Medical Social Worker - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.8"},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"Medical Social Worker - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.9"},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"Medical Social Worker - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.10"},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Chaplain or Spiritual Counselor - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.11"},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Chaplain or Spiritual Counselor -Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.12"},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Chaplain or Spiritual Counselor - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.13"},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Licensed Professional Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.14"},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Licensed Professional Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.15"},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Licensed Professional Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.16"},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Aide - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.17"},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Aide - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.18"},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Aide - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.19"},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Level of care in final 7 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.20"},{"linkId":"Section-50/O5030","prefix":"O5030","text":"Number of hospice visits in 3 to 6 days prior to death. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3"}],"id":"item.5.item.21"},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"Registered Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.22"},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"Registered Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.23"},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"Registered Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.24"},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"Registered Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.25"},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.26"},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.27"},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.28"},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.29"},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Medical Social Worker - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.30"},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"Medical Social Worker - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.31"},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"Medical Social Worker - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.32"},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"Medical Social Worker - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.33"},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Chaplain or Spiritual Counselor - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.34"},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"Chaplain or Spiritual Counselor - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.35"},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"Chaplain or Spiritual Counselor - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.36"},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Chaplain or Spiritual Counselor - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.37"},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"Licensed Professional Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.38"},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"Licensed Professional Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.39"},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Licensed Professional Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.40"},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"Licensed Professional Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.41"},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Aide - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.42"},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"Aide - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.43"},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Aide - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.44"},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Aide - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.45"}],"id":"item.5","description":"In section O of the form, the patient's service utilization is assessed."},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.0","description":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final three days of their life?"},{"linkId":"Section-50/O5010","prefix":"O5010","text":"Number of hospice visits in final 3 days. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0"},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1"},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2"}],"id":"item.5.item.1","description":"The form requires the patient to enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated, specifically focusing on the final three days of hospice care."},{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0","description":"The number of hospice visits the patient had on the day of their death."},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1","description":"The form asked the patient how many hospice visits they had one day prior to their death."},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2","description":"How many hospice visits did the patient have two days prior to death?"},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Registered Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.2","description":"Did the registered nurse visit the patient on the day of death?"},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"Registered Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.3","description":"The registered nurse visited the patient one day prior to their death."},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"Registered Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.4","description":"Did the registered nurse visit the patient two days prior to their death?"},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.5","description":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant on the day of their death?"},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.6","description":"Did the patient have a visit from a physician, nurse practitioner, or physician assistant one day prior to their death?"},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.7","description":"Did the patient visit a physician, nurse practitioner, or physician assistant two days prior to their death?"},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"Medical Social Worker - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.8","description":"Did the medical social worker visit the patient on the day of their death?"},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"Medical Social Worker - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.9","description":"The medical social worker visited the patient one day prior to their death."},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"Medical Social Worker - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.10","description":"The medical social worker visited the patient two days prior to their death."},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Chaplain or Spiritual Counselor - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.11","description":"Did the patient receive a visit from a Chaplain or Spiritual Counselor on the day of their death?"},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Chaplain or Spiritual Counselor -Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.12","description":"Did the patient receive a visit from a chaplain or spiritual counselor one day prior to their death?"},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Chaplain or Spiritual Counselor - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.13","description":"Did the patient receive a visit from a chaplain or spiritual counselor two days prior to death?"},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Licensed Professional Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.14","description":"Did the Licensed Professional Nurse visit the patient on the day of their death?"},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Licensed Professional Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.15","description":"Did the licensed professional nurse visit the patient one day prior to their death?"},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Licensed Professional Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.16","description":"The patient was visited by a Licensed Professional Nurse two days prior to their death."},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Aide - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.17","description":"Did the aide visit the patient on the day of death?"},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Aide - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.18","description":"Did the aide visit the patient one day prior to their death?"},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Aide - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.19","description":"Did the patient receive an aide visit two days prior to death?"},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Level of care in final 7 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.20","description":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final seven days of their life?"},{"linkId":"Section-50/O5030","prefix":"O5030","text":"Number of hospice visits in 3 to 6 days prior to death. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3"}],"id":"item.5.item.21","description":"The form is asking for the number of visits the patient received from hospice staff in the 3 to 6 days prior to their death. The respondent should enter the number of visits provided by hospice staff from the indicated discipline, on each of the specified dates."},{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0","description":"How many hospice visits did the patient have three days prior to death?"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1","description":"How many hospice visits did the patient have four days prior to death in the period of 3 to 6 days before death?"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2","description":"How many hospice visits did the patient have five days prior to death?"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3","description":"How many hospice visits did the patient have in the six days prior to their death?"},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"Registered Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.22","description":"The patient was visited by a registered nurse three days prior to their death."},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"Registered Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.23","description":"The registered nurse visited the patient four days prior to their death."},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"Registered Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.24","description":"The registered nurse visited the patient five days prior to their death."},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"Registered Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.25","description":"The registered nurse visited the patient six days prior to their death."},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.26","description":"Did the patient visit a physician, nurse practitioner, or physician assistant three days prior to death?"},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.27","description":"The patient visited the physician, nurse practitioner, or physician assistant four days prior to their death."},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.28","description":"Did the patient visit a physician, nurse practitioner, or physician assistant five days prior to their death?"},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.29","description":"The patient was visited by a physician, nurse practitioner, or physician assistant six days prior to death."},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Medical Social Worker - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.30","description":"The medical social worker visited the patient three days prior to their death."},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"Medical Social Worker - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.31","description":"The medical social worker visited the patient four days prior to their death."},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"Medical Social Worker - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.32","description":"The medical social worker visited the patient five days prior to their death."},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"Medical Social Worker - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.33","description":"The medical social worker visited the patient six days prior to their death."},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Chaplain or Spiritual Counselor - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.34","description":"Did the patient receive a visit from a chaplain or spiritual counselor three days prior to death?"},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"Chaplain or Spiritual Counselor - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.35","description":"Did the patient receive a visit from a chaplain or spiritual counselor four days prior to death?"},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"Chaplain or Spiritual Counselor - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.36","description":"Did the patient receive visits from a chaplain or spiritual counselor five days prior to death?"},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Chaplain or Spiritual Counselor - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.37","description":"Did the patient receive a visit from a chaplain or spiritual counselor six days prior to death?"},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"Licensed Professional Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.38","description":"The licensed professional nurse visited the patient three days prior to their death."},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"Licensed Professional Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.39","description":"The Licensed Professional Nurse visited the patient four days prior to their death."},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Licensed Professional Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.40","description":"The patient was visited by a licensed professional nurse five days prior to their death."},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"Licensed Professional Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.41","description":"The Licensed Professional Nurse visited the patient six days prior to their death."},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Aide - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.42","description":"The patient had visits from an aide three days prior to their death."},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"Aide - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.43","description":"Did the aide visit the patient four days prior to death?"},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Aide - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.44","description":"Did the patient receive aid visits five days prior to death?"},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Aide - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.45","description":"Did the aide visit the patient six days prior to death?"},{"linkId":"Section-48","text":"Section Z: Record Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0"},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1"}],"id":"item.6","description":"In Section Z, the record administration pertaining to the patient needs to be filled out."},{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0","description":"The signature of the person who completed the patient's assessment is required."},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0","description":"The patient needs to provide their signature, title, and the date on which they completed section A."},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1","description":"The patient is required to provide their signature and title, and then complete section B, after which they must record the date the section was completed."},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2","description":"The patient should provide their signature, title, and date in the section marked 'C'."},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3","description":"The patient was required to provide their signature and title, fill out several sections, and note down the date they completed section D."},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4","description":"\"The patient is required to provide a signature, title, and complete various sections. They also need to provide the date on which the section E was completed.\""},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5","description":"The patient completed the sections of the form and signed it, indicating their title and date when they finished section F."},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6","description":"The patient needs to provide their signature, title, and the date the sections were completed in Section G."},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7","description":"The patient needs to provide their signature, title, and the date on which the form section H was completed."},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8","description":"The patient is required to provide their signature, title, the sections they have completed, and the date on which the section was completed."},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9","description":"The patient's form includes their signature, title, date, and the sections they completed, specifically section J."},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10","description":"The patient is required to provide their signature, title, and the date on which the sections were completed."},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11","description":"The form for the patient includes sections for a signature, title, and the date when the section was completed."},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1","description":"The signature of the RN Coordinator is required to verify the completion of the patient's assessment."},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0","description":"The form requires the patient's signature."},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1","description":"The date when the Registered Nurse Assessment Coordinator signed the patient's assessment as complete."},null],"_id":"R57CTL7MkNri5WKCo"} {"responseType":"QuestionnaireResponse","questionnaire":"IRF-PAI-IA-3.0","id":"IRF-PAI-IA-3.0-1","title":"Inpatient Rehabilitation Facility Patient Assessment Instrument - IRF Admission","description":"Assessment data collected on all Medicare Part A fee-for-service patients who receive services under Part A from an inpatient rehabilitation facility (IRF) at admission and upon discharge.","status":"draft","authored":"2024-09-20T06:34:32.500Z","item":[{"linkId":"Section-45","text":"Discharge Information","type":"group","readOnly":true,"item":[{"linkId":"Section-45/40","prefix":"40","text":"Discharge date","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.0"}],"id":"item.0","description":"The patient's discharge information is ready to be reviewed."},{"linkId":"Section-45/40","prefix":"40","text":"Discharge date","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.0","description":"What is the patient's discharge date?"},{"linkId":"Section-38","code":[{"system":"http://loinc.org","code":"85395-2","display":"IRF-PAI v3.0 - Identification information [CMS Assessment]"}],"text":"Identification Information","type":"group","readOnly":true,"item":[{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.0"},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.1"},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.1.item.2"},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.1.item.3"},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.4"},{"linkId":"Section-38/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.1.item.5"},{"linkId":"Section-38/A0800","prefix":"A0800","text":"Gender","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}],"id":"item.1.item.6"},{"linkId":"Section-38/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.7"},{"linkId":"Section-38/A1200","prefix":"A1200","text":"Marital Status","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}],"id":"item.1.item.8"},{"linkId":"Section-38/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.9"},{"linkId":"Section-38/11","prefix":"11","text":"Zip Code of {Patient's/Resident's} Pre-Hospital Residence","type":"text","repeats":false,"readOnly":false,"maxLength":5,"id":"item.1.item.10"},{"linkId":"Section-38/13","prefix":"13","text":"Assessment Reference Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.11"},{"linkId":"Section-38/14","prefix":"14","text":"Admission Class","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27331-0","display":"Initial rehab"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27332-8","display":"Evaluation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4395-5","display":"Readmission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27335-1","display":"Continuing rehabilitation"}}],"id":"item.1.item.12"},{"linkId":"Section-38/17","prefix":"17","text":"Pre-hospital Living With (Code only if item {Pre-hospital Living Setting} is Home)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27350-0","display":"Alone"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27351-8","display":"Family/Relatives"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27352-6","display":"Friends"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27353-4","display":"Attendant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}],"id":"item.1.item.13"},{"linkId":"Section-38/15A","prefix":"15A","text":"Admit From","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.14"},{"linkId":"Section-38/16A","prefix":"16A","text":"Pre-hospital Living Setting. Use codes from {Admit From}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.15"},{"linkId":"Section-38/1","prefix":"1","text":"{Facility/Provider} Information","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0"}],"id":"item.1.item.16"},{"linkId":"Section-38/5B","prefix":"5B","text":"{Patient/Resident} Identification Number","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.17"},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}],"id":"item.1.item.18"}],"id":"item.1","description":"The form requires the patient's identification information."},{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.0","description":"What is the patient's CMS Certification Number (CCN)?"},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.1","description":"What is the patient's first name?"},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.1.item.2","description":"What is the patient's last name?"},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.1.item.3","description":"What is the patient's Social Security Number?"},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.4","description":"What is the patient's Medicare number?"},{"linkId":"Section-38/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.1.item.5","description":"The patient should enter a \"+\" in the section labeled \"Medicaid Number\" if their Medicaid application is pending, or a \"N\" if they are not a Medicaid recipient."},{"linkId":"Section-38/A0800","prefix":"A0800","text":"Gender","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}],"id":"item.1.item.6","description":"What is the patient's gender? The options are male, female, or other."},{"linkId":"Section-38/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.7","description":"What is the patient's birth date?"},{"linkId":"Section-38/A1200","prefix":"A1200","text":"Marital Status","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}],"id":"item.1.item.8","description":"What is the patient's marital status? Is they married, single, divorced, or widowed?"},{"linkId":"Section-38/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.9","description":"The admission date of the patient is when they were admitted to the hospital."},{"linkId":"Section-38/11","prefix":"11","text":"Zip Code of {Patient's/Resident's} Pre-Hospital Residence","type":"text","repeats":false,"readOnly":false,"maxLength":5,"id":"item.1.item.10","description":"What is the zip code of the patient's pre-hospital residence?"},{"linkId":"Section-38/13","prefix":"13","text":"Assessment Reference Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.11","description":"The assessment reference date for the patient has been set."},{"linkId":"Section-38/14","prefix":"14","text":"Admission Class","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27331-0","display":"Initial rehab"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27332-8","display":"Evaluation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4395-5","display":"Readmission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27335-1","display":"Continuing rehabilitation"}}],"id":"item.1.item.12","description":"The admission class for the patient is being determined."},{"linkId":"Section-38/17","prefix":"17","text":"Pre-hospital Living With (Code only if item {Pre-hospital Living Setting} is Home)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Alone"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27350-0","display":"Alone"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Family / Relatives"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27351-8","display":"Family/Relatives"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Friends"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27352-6","display":"Friends"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Attendant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27353-4","display":"Attendant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Other"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}],"id":"item.1.item.13","description":"The patient's pre-hospital living situation should be coded only if the patient was living at home before hospitalization."},{"linkId":"Section-38/15A","prefix":"15A","text":"Admit From","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.14","description":"From where was the patient admitted?"},{"linkId":"Section-38/16A","prefix":"16A","text":"Pre-hospital Living Setting. Use codes from {Admit From}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.15","description":"The pre-hospital living setting of the patient is determined by using codes from the 'Admit From' category."},{"linkId":"Section-38/1","prefix":"1","text":"{Facility/Provider} Information","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0"}],"id":"item.1.item.16","description":"The form contains a section for the patient to provide information about the facility or provider they are connected with.\n"},{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0","description":"What is the name of the facility or provider for the patient?"},{"linkId":"Section-38/5B","prefix":"5B","text":"{Patient/Resident} Identification Number","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.17","description":"What is the patient's or resident's identification number?"},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}],"id":"item.1.item.18","description":"The patient should check all the boxes that apply to their race or ethnicity."},{"linkId":"Section-41","code":[{"system":"http://loinc.org","code":"87415-6","display":"IRF-PAI v3.0 - Medical Info [CMS Assessment]"}],"text":"Medical Information","type":"group","readOnly":true,"item":[{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Height (in inches). Record most recent height measure since {admission}","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"Weight (in pounds). Base weight on most recent measure in last {specify time period in days}; measure weight consistently, according to standard {facility/setting} practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer","repeats":false,"readOnly":false,"maxLength":3,"id":"item.2.item.1"},{"linkId":"Section-41/21A","prefix":"21A","text":"Impairment Group - Admission: Condition requiring admission to rehabilitation; code according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.2.item.2"},{"linkId":"Section-41/23","prefix":"23","text":"Date of Onset of Impairment","type":"open-choice","repeats":false,"readOnly":false,"id":"item.2.item.3"},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Are there any arthritis conditions recorded in items {impairment group, etiologic diagnosis, or comorbid conditions} that meet all the regulatory requirements for {IRF} classification","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.2.item.4"},{"linkId":"Section-41/22","prefix":"22","text":"Etiologic Diagnosis: (Use ICD codes to indicate the etiologic problem that led to the condition for which the {patient/resident} is receiving rehabilitation)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0"},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1"},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2"}],"id":"item.2.item.5"},{"linkId":"Section-41/24","prefix":"24","text":"Comorbid Conditions. Use ICD codes to enter comorbid medical conditions","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8"},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18"},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21"},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24"}],"id":"item.2.item.6"},{"linkId":"Section-41/21","prefix":"21","text":"Impairment group","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0"}],"id":"item.2.item.7"}],"id":"item.2","description":"The form is requesting the patient's medical information."},{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Height (in inches). Record most recent height measure since {admission}","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"The form asks for the patient's height in inches and requests the most recent measurement since their admission."},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"Weight (in pounds). Base weight on most recent measure in last {specify time period in days}; measure weight consistently, according to standard {facility/setting} practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer","repeats":false,"readOnly":false,"maxLength":3,"id":"item.2.item.1","description":"The patient's weight, in pounds, should be based on the most recent measurement taken within the specified time period in days. It's important to measure the patient's weight consistently, adhering to the standard practice of the facility or setting. For instance, this could be done in the morning after voiding, before a meal, with shoes off, and so on."},{"linkId":"Section-41/21A","prefix":"21A","text":"Impairment Group - Admission: Condition requiring admission to rehabilitation; code according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.2.item.2","description":"The impairment group on the admission form refers to the condition that required the patient's admission to rehabilitation, which should be coded according to Appendix A."},{"linkId":"Section-41/23","prefix":"23","text":"Date of Onset of Impairment","type":"open-choice","repeats":false,"readOnly":false,"id":"item.2.item.3","description":"When did the patient's impairment begin?"},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Are there any arthritis conditions recorded in items {impairment group, etiologic diagnosis, or comorbid conditions} that meet all the regulatory requirements for {IRF} classification","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.2.item.4","description":"Does the patient have any arthritis conditions recorded in the impairment group, etiologic diagnosis, or comorbid conditions that meet all the regulatory requirements for Inpatient Rehabilitation Facility (IRF) classification?"},{"linkId":"Section-41/22","prefix":"22","text":"Etiologic Diagnosis: (Use ICD codes to indicate the etiologic problem that led to the condition for which the {patient/resident} is receiving rehabilitation)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0"},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1"},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2"}],"id":"item.2.item.5","description":"The etiologic diagnosis requires the use of ICD codes to indicate the underlying problem that led to the condition for which the patient is receiving rehabilitation."},{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0","description":"The form for the patient includes a section labeled \"Etiologic Diagnosis A\"."},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1","description":"The form for the patient includes a section labeled \"Etiologic Diagnosis B\"."},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2","description":"The form asks for the patient's etiologic diagnosis C."},{"linkId":"Section-41/24","prefix":"24","text":"Comorbid Conditions. Use ICD codes to enter comorbid medical conditions","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8"},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18"},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21"},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24"}],"id":"item.2.item.6","description":"The patient is instructed to use ICD codes to enter their comorbid medical conditions under the section labeled \"Comorbid Conditions.\""},{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0","description":"Does the patient have a comorbid condition A?"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1","description":"Does the patient have Comorbid Condition B?"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2","description":"Does the patient have Comorbid Condition C?"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3","description":"Does the patient have any comorbid condition D?"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4","description":"Does the patient have a comorbid condition E?"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5","description":"Does the patient have a comorbid condition F?"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6","description":"Does the patient have comorbid condition G?"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7","description":"Does the patient have a comorbid condition H?"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8","description":"Does the patient have a comorbid condition? If yes, please specify."},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9","description":"Does the patient have Comorbid Condition J?"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10","description":"Does the patient have a comorbid condition K?"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11","description":"Does the patient have any comorbid condition L?"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12","description":"Does the patient have a comorbid condition M?"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13","description":"Does the patient have a comorbid condition N?"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14","description":"Does the patient have any comorbid conditions?"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15","description":"Does the patient have a comorbid condition P?"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16","description":"Does the patient have a comorbid condition?"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17","description":"Does the patient have a comorbid condition R?"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18","description":"The form asks if the patient has any comorbid conditions."},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19","description":"Does the patient have a comorbid condition T?"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20","description":"Does the patient have a comorbid condition U?"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21","description":"Does the patient have a comorbid condition V? Please indicate yes or no."},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22","description":"Does the patient have any comorbid condition W?"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23","description":"Does the patient have a comorbid condition X?"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24","description":"Does the patient have comorbid condition Y?"},{"linkId":"Section-41/21","prefix":"21","text":"Impairment group","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0"}],"id":"item.2.item.7","description":"What is the patient's impairment group?"},{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0","description":"What is the impairment group upon admission for the patient?"},{"linkId":"Section-40","code":[{"system":"http://loinc.org","code":"85401-8","display":"IRF-PAI - Payer information [CMS Assessment]"}],"text":"Payer Information","type":"group","readOnly":true,"item":[{"linkId":"Section-40/20","prefix":"20","text":"Payment Source","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0"},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1"}],"id":"item.3.item.0"}],"id":"item.3","description":"The form requires the patient's payer information."},{"linkId":"Section-40/20","prefix":"20","text":"Payment Source","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0"},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1"}],"id":"item.3.item.0","description":"The payment source for the patient is being determined."},{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0","description":"The primary source of information regarding the patient's health condition is the patient themselves."},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1","description":"The form for the patient includes a section titled \"Secondary Source.\""},{"linkId":"Section-2","code":[{"system":"http://loinc.org","code":"88522-8","display":"IRF-PAI v2.0 - Hearing, speech, and vision - admission [CMS Assessment]"}],"text":"Section B: Hearing, Speech, and Vision","type":"group","readOnly":true,"item":[{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}],"id":"item.4.item.0"},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}],"id":"item.4.item.1"}],"id":"item.4","description":"In Section B of the form, the patient's hearing, speech, and vision capabilities are assessed."},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}],"id":"item.4.item.0","description":"The patient's expression of ideas and wants, considering both verbal and non-verbal expression and excluding language barriers, should be evaluated. Does the patient often communicate their ideas and desires clearly? The answer could be 'Always', 'Often', 'Sometimes', 'Rarely', or 'Never'."},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}],"id":"item.4.item.1","description":"Does the patient understand both verbal and non-verbal content with the use of a hearing aid or device, if used, while excluding any language barriers?"},{"linkId":"Section-3","code":[{"system":"http://loinc.org","code":"88524-4","display":"IRF-PAI v2.0 - Cognitive patterns - admission [CMS Assessment]"}],"text":"Section C: Cognitive Patterns","type":"group","readOnly":true,"item":[{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all {patients/residents}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.5.item.0"},{"linkId":"Section-3/C0200","prefix":"C0200","text":"Repetition of Three Words - Ask {patient/resident}: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}],"id":"item.5.item.1"},{"linkId":"Section-3/C0500","prefix":"C0500","text":"BIMS Summary Score. Add scores for {Brief Interview for Mental Status questions} and fill in total score (00-15). Enter 99 if the {patient/resident} was unable to complete the interview","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.2"},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the Staff Assessment for Mental Status be Conducted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes ({patient/resident} was unable to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}],"id":"item.5.item.3"},{"linkId":"Section-3/C0300","prefix":"C0300","text":"BIMS: Temporal Orientation (orientation to year, month, and day)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0"},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1"},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2"}],"id":"item.5.item.4"},{"linkId":"Section-3/C0400","prefix":"C0400","text":"Recall. Ask {patient/resident}: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0"},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1"},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2"}],"id":"item.5.item.5"},{"linkId":"Section-3/C0900","prefix":"C0900","text":"Memory/Recall Ability: Check all that the {patient/resident} was normally able to recall","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above were recalled"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}],"id":"item.5.item.6"}],"id":"item.5","description":"In Section C of the form, the patient's cognitive patterns are assessed."},{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all {patients/residents}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.5.item.0","description":"Should a Brief Interview for Mental Status be conducted? It is suggested to attempt to conduct the interview with all patients or residents."},{"linkId":"Section-3/C0200","prefix":"C0200","text":"Repetition of Three Words - Ask {patient/resident}: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}],"id":"item.5.item.1","description":"The form asks the patient, \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" The number of words repeated after the first attempt is then recorded by the medical professional."},{"linkId":"Section-3/C0500","prefix":"C0500","text":"BIMS Summary Score. Add scores for {Brief Interview for Mental Status questions} and fill in total score (00-15). Enter 99 if the {patient/resident} was unable to complete the interview","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.2","description":"The BIMS Summary Score should be calculated by adding the scores for the Brief Interview for Mental Status questions and filling in the total score, which ranges from 00 to 15. If the patient or resident was unable to complete the interview, the score to be entered should be 99."},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the Staff Assessment for Mental Status be Conducted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes ({patient/resident} was unable to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}],"id":"item.5.item.3","description":"Should the staff assessment for the patient's mental status be conducted?"},{"linkId":"Section-3/C0300","prefix":"C0300","text":"BIMS: Temporal Orientation (orientation to year, month, and day)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0"},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1"},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2"}],"id":"item.5.item.4","description":"The patient's BIMS assessment includes a temporal orientation evaluation, which evaluates their orientation to the current year, month, and day."},{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0","description":"The form asks the patient or resident, \"Please tell me what year it is right now.\" They are able to report the correct year."},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1","description":"The form asks the patient or resident, \"What month are we in right now?\" The patient or resident should be able to report the correct month."},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2","description":"Ask the patient or resident: \"What day of the week is today?\" They should be able to report the correct day of the week."},{"linkId":"Section-3/C0400","prefix":"C0400","text":"Recall. Ask {patient/resident}: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0"},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1"},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2"}],"id":"item.5.item.5","description":"The doctor asks the patient, \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If the patient is unable to remember a word, the doctor gives a cue, such as 'something to wear', 'a color', or 'a piece of furniture', for that particular word."},{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0","description":"The patient is able to recall the word \"sock\"."},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1","description":"The patient is able to recall the color \"blue\"."},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2","description":"Is the patient able to recall \"bed\"?"},{"linkId":"Section-3/C0900","prefix":"C0900","text":"Memory/Recall Ability: Check all that the {patient/resident} was normally able to recall","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above were recalled"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}],"id":"item.5.item.6","description":"The patient's or resident's ability to recall normally should be assessed. Please check all that apply."},{"linkId":"Section-37","code":[{"system":"http://loinc.org","code":"88482-5","display":"Functional abilities and goals - admission [CMS Assessment]"}],"text":"Section GG: Functional Abilities and Goals","type":"group","readOnly":true,"item":[{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.0"},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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If managing an ostomy, include wiping the opening but not managing equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.13"},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.14"},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.28"},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the {patient/resident} use a wheelchair and/or scooter? - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.6.item.29"},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.30"},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.31"},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.32"},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.33"},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.34"},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.35"},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.36"},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.37"},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.45"},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.46"},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.47"},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.48"},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"4 steps: The ability to go up and down four steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.49"},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.50"},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.51"},{"linkId":"Section-37/GG0100","prefix":"GG0100","text":"Prior Functioning: Everyday Activities. Indicate the {patient's/resident's} usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0"},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1"},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2"},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3"}],"id":"item.6.item.52"},{"linkId":"Section-37/GG0130","prefix":"GG0130","text":"Self-Care.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0"},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1"}],"id":"item.6.item.53"},{"linkId":"Section-37/GG0170","prefix":"GG0170","text":"Mobility.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0"},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1"}],"id":"item.6.item.54"},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Prior Device Use. Indicate devices and aids used by the {patient/resident} prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.6.item.55"}],"id":"item.6","description":"In Section GG of the form, the patient's functional abilities and goals are documented."},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.0","description":"The question for the patient or resident is about their eating ability. Specifically, can they use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them? This is in reference to their performance upon admission."},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.1","description":"The form asks about the patient's oral hygiene, specifically their ability to use suitable items to clean their teeth. It also inquires if they have dentures and if so, their ability to insert and remove them from the mouth, as well as manage denture soaking and rinsing with the use of equipment. This is relevant to their admission performance."},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.2","description":"The form asks about the patient's ability to maintain perineal hygiene and adjust their clothes before and after voiding or having a bowel movement. If the patient is managing an ostomy, it includes the task of wiping the opening but not managing the equipment. This is pertaining to their performance upon admission."},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.3","description":"The discharge goal for the patient is to have the ability to use suitable utensils in order to bring food and/or liquid to their mouth and to be able to swallow food and/or liquid once the meal is placed before them."},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.4","description":"The form inquires about the patient's oral hygiene: their ability to use suitable items to clean their teeth. It also asks if the patient has dentures and if so, it assesses their ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with the use of equipment. The goal is to prepare the patient for discharge."},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.5","description":"The discharge goal for the patient is related to toileting hygiene, which refers to their ability to maintain perineal hygiene, adjust clothing before and after voiding or having a bowel movement. If they are managing an ostomy, this also includes wiping the opening, but not managing the equipment."},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.6","description":"The form asks about the patient's ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed, as part of their admission performance."},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.7","description":"The form asks about the patient's admission performance regarding their ability to move from sitting on the side of the bed to lying flat on the bed."},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.8","description":"The form is asking about the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. This is in reference to their admission performance."},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.9","description":"The discharge goal for the patient is to acquire the ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed."},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.10","description":"The discharge goal for the patient is to have the ability to move from sitting on the side of the bed to lying flat on the bed."},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.11","description":"The discharge goal for the patient is to have the ability to move from lying on their back to sitting on the side of the bed without any back support."},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.12","description":"The form asks the patient about their ability to come to a standing position from sitting in a chair, a wheelchair, or on the side of the bed, and requests them to rate their admission performance."},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.13","description":"The form is asking about the patient's ability to transfer to and from a bed to a chair or wheelchair. It is inquiring about their admission performance."},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.14","description":"The form asks about the patient's ability to transfer to and from a toilet or commode on their own as it pertains to their performance upon admission."},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.15","description":"The question on the form asks about the patient's admission performance in relation to their ability to walk. Specifically, it inquires whether, once standing, the patient can walk at least 10 feet in a room, corridor, or similar space."},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.16","description":"Once standing, the patient has the ability to walk at least 50 feet and make two turns as part of their admission performance."},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.17","description":"The form inquires about the patient's capability to walk at least 150 feet in a corridor or similar space once they are standing. This is referred to as the \"Admission Performance\" aspect."},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.18","description":"Once the patient is seated in the wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. This is a requirement for admission performance."},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.19","description":"The admission performance form includes a question regarding the patient's ability, once seated in a wheelchair or scooter, to wheel at least 150 feet in a corridor or similar space."},{"linkId":"Section-37/GG0170K3","prefix":"GG0170K3","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Discharge Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.20","description":"The form asks about the patient's ability to walk at least 150 feet in a corridor or similar space once they are standing, with the label of \"Discharge Performance\"."},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.21","description":"The discharge goal for the patient is to develop the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed."},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.22","description":"The form asks about the patient's ability to transfer themselves to and from a bed to a chair or wheelchair. The discharge goal is to evaluate this capability."},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.23","description":"The discharge goal for the patient refers to their ability to independently get on and off a toilet or commode."},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.24","description":"The question on the form is asking about the patient's ability, once standing, to walk at least 10 feet in a room, corridor, or similar space. The goal is that the patient should be able to do this upon discharge."},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.25","description":"The label is asking about the patient's ability, once standing, to walk a minimum of 50 feet and make two turns. The goal is to achieve this by the time of discharge."},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.26","description":"The form asks if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The response options for this question are 'discharge goal'."},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.27","description":"The discharge goal for the patient is to be able to wheel at least 50 feet and make two turns once seated in a wheelchair or scooter."},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.28","description":"The discharge goal for the patient is to gain the ability to wheel at least 150 feet in a corridor or similar space once seated in a wheelchair or scooter."},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the {patient/resident} use a wheelchair and/or scooter? - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.6.item.29","description":"Does the patient or resident use a wheelchair and/or scooter upon admission?"},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.30","description":"The form is asking the patient to indicate the type of wheelchair or scooter they use upon admission."},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.31","description":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission."},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.32","description":"The form asks about the patient's ability to shower or bathe themselves, which includes tasks such as washing, rinsing, and drying themselves, but does not include washing their back and hair, nor transferring in and out of the tub or shower. The question relates to their performance upon admission."},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.33","description":"The admission form inquires about the patient's ability to dress and undress above the waist, including handling fasteners if applicable, in the section labeled \"Upper body dressing.\""},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.34","description":"On the admission performance form, there is a question about the patient's ability to dress and undress below the waist, including handling fasteners. This does not include dealing with footwear."},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.35","description":"Does the patient have the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable? Please evaluate their performance upon admission."},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.36","description":"On the admission form, it asks about the patient's ability to transfer in and out of a car or van on the passenger side, without including the ability to open or close the door or fasten the seat belt."},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.37","description":"The form asks if the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, either indoors or outdoors. This is in reference to their admission performance."},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.38","description":"The form asks about the patient's ability to go up and down a curb and/or up and down one step in regards to their admission performance."},{"linkId":"Section-37/GG0170N1","prefix":"GG0170N1","text":"4 steps: The ability to go up and down four steps with or without a rail. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.39","description":"The form asks about the patient's ability to go up and down four steps with or without a rail in terms of admission performance."},{"linkId":"Section-37/GG0170O1","prefix":"GG0170O1","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.40","description":"The form asks whether the patient has the ability to go up and down 12 steps with or without a rail as part of their admission performance."},{"linkId":"Section-37/GG0170P1","prefix":"GG0170P1","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.41","description":"The form asks about the patient's admission performance in terms of their ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor."},{"linkId":"Section-37/GG0130E2","prefix":"GG0130E2","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.42","description":"The discharge goal for the patient is to be able to shower or bathe themselves. This means the patient should have the ability to wash, rinse, and dry themselves, excluding washing of the back and hair. It does not include transferring in or out of the tub or shower."},{"linkId":"Section-37/GG0130F2","prefix":"GG0130F2","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.43","description":"The discharge goal for the patient is to be able to dress and undress above the waist, which includes handling any fasteners, if applicable, on their own."},{"linkId":"Section-37/GG0130G2","prefix":"GG0130G2","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.44","description":"The discharge goal for the patient is to be able to independently dress and undress their lower body, below the waist, including handling fasteners, but not including footwear."},{"linkId":"Section-37/GG0130H2","prefix":"GG0130H2","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.45","description":"The form asks about the patient's ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable, and what the discharge goal for this ability is."},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.46","description":"The discharge goal for the patient is to have the ability to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten their seat belt."},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.47","description":"The form asks if the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoor or outdoor, with the discharge goal being the endpoint."},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.48","description":"The question on the form asks about the patient's ability to go up and down a curb and/or up and down one step. The label for this section is \"Discharge Goal\"."},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"4 steps: The ability to go up and down four steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.49","description":"The discharge goal for the patient is to have the ability to go up and down four steps with or without a rail."},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.50","description":"The discharge goal for the patient is to develop the ability to go up and down 12 steps with or without the use of a rail."},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.51","description":"The discharge goal for the patient is to have the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor."},{"linkId":"Section-37/GG0100","prefix":"GG0100","text":"Prior Functioning: Everyday Activities. Indicate the {patient's/resident's} usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0"},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1"},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2"},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3"}],"id":"item.6.item.52","description":"Please indicate the patient's usual ability with everyday activities prior to their current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0","description":"Please code the patient's or resident's need for assistance with bathing, dressing, using the toilet, and eating prior to their current illness, exacerbation, or injury for the Self-Care section."},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1","description":"The form requests the code for the patient's or resident's need for assistance with walking from room to room, with or without a device such as a cane, crutch, or walker, prior to the current illness, exacerbation, or injury to determine their level of indoor mobility and ambulation."},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2","description":"The form asks to code the patient's or resident's need for assistance with internal or external stairs, with or without a device such as a cane, crutch, or walker, prior to the current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3","description":"The form asks to code the patient's or resident's need for assistance with planning regular tasks, such as shopping or remembering to take medication, prior to their current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0130","prefix":"GG0130","text":"Self-Care.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0"},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1"}],"id":"item.6.item.53","description":"The patient is capable of self-care."},{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0","description":"For the category of Self-Care, please code the patient's usual performance at the time of admission for each activity using the 6-point scale. If the activity was not attempted at the time of admission, please code the reason."},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1","description":"Please code the patient's or resident's self-care discharge goals using the 6-point scale. The use of codes 07, 09, 10, or 88 is permissible to code the discharge goals."},{"linkId":"Section-37/GG0170","prefix":"GG0170","text":"Mobility.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0"},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1"}],"id":"item.6.item.54","description":"The patient's mobility status is being assessed."},{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0","description":"For the section on mobility, please code the patient's or resident's usual performance at the time of admission for each activity using the 6-point scale. If a certain activity was not attempted at the time of admission, code the reason."},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1","description":"The form instructs the user to code the patient's or resident's discharge goals using the 6-point scale. The use of codes 07, 09, 10, or 88 is permissible to code the discharge goals."},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Prior Device Use. Indicate devices and aids used by the {patient/resident} prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.6.item.55","description":"Please indicate the devices and aids that the patient or resident used prior to their current illness, exacerbation, or injury. Check all that apply."},{"linkId":"Section-8","code":[{"system":"http://loinc.org","code":"83237-8","display":"Bladder and bowel [CMS Assessment]"}],"text":"Section H: Bladder and Bowel","type":"group","readOnly":true,"item":[{"linkId":"Section-8/H0400","prefix":"H0400","text":"Bowel Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}],"id":"item.7.item.0"},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Bladder Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}],"id":"item.7.item.1"}],"id":"item.7","description":"In section H of the form, the patient's bladder and bowel conditions are addressed."},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Bowel Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}],"id":"item.7.item.0","description":"Please select the one category that best describes the bowel continence of the patient or resident."},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Bladder Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}],"id":"item.7.item.1","description":"Please select the one category that best describes the patient's or resident's bladder continence."},{"linkId":"Section-9","code":[{"system":"http://loinc.org","code":"83264-2","display":"IRF-PAI - Active diagnoses [CMS Assessment]"}],"text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0000","prefix":"I0000","text":"Active Diagnoses in the last 7 days: Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.8.item.0"}],"id":"item.8","description":"In Section I of the form, the patient's active diagnoses are listed."},{"linkId":"Section-9/I0000","prefix":"I0000","text":"Active Diagnoses in the last 7 days: Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.8.item.0","description":"The patient has been asked to indicate all of their active diagnoses from the last 7 days on the form. They should check all that apply. The diagnoses provided in parentheses are just examples and should not be considered as an all-inclusive list."},{"linkId":"Section-10","code":[{"system":"http://loinc.org","code":"83273-3","display":"IRF-PAI - Health conditions - admission [CMS Assessment]"}],"text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J1750","prefix":"J1750","text":"History of Falls: Has the {patient/resident} had two or more falls in the past year or any fall with injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.0"},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Prior Surgery. Did the {patient/resident} have major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.1"}],"id":"item.9","description":"In Section J of the form, the patient's health conditions are being evaluated."},{"linkId":"Section-10/J1750","prefix":"J1750","text":"History of Falls: Has the {patient/resident} had two or more falls in the past year or any fall with injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.0","description":"Does the patient or resident have a history of having two or more falls in the past year, or any fall that resulted in injury in the past year?"},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Prior Surgery. Did the {patient/resident} have major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.1","description":"Did the patient or resident have any major surgery during the 100 days prior to their admission?"},{"linkId":"Section-11","code":[{"system":"http://loinc.org","code":"83244-4","display":"IRF-PAI v2.0 - Swallowing/nutritional status - admission [CMS Assessment]"}],"text":"Section K: Swallowing/Nutritional Status","type":"group","readOnly":true,"item":[{"linkId":"Section-11/K0110","prefix":"K0110","text":"Swallowing/Nutritional Status. Indicate the {patient's/resident's} usual ability to swallow: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Regular food - Solids and liquids swallowed safely without supervision or modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Modified food consistency/supervision - {Patient/Resident} requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Tube/parenteral feeding - Tube/parenteral feeding used wholly or partially as a means of sustenance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}],"id":"item.10.item.0"}],"id":"item.10","description":"In Section K of the form, the patient's swallowing and nutritional status is assessed."},{"linkId":"Section-11/K0110","prefix":"K0110","text":"Swallowing/Nutritional Status. Indicate the {patient's/resident's} usual ability to swallow: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Regular food - Solids and liquids swallowed safely without supervision or modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Modified food consistency/supervision - {Patient/Resident} requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Tube/parenteral feeding - Tube/parenteral feeding used wholly or partially as a means of sustenance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}],"id":"item.10.item.0","description":"Please indicate the patient's usual ability to swallow regarding their swallowing or nutritional status. Check all that apply."},{"linkId":"Section-13","code":[{"system":"http://loinc.org","code":"85055-2","display":"IRF-PAI v3.0, LCDS v4.00 - Skin conditions - admission [CMS Assessment]"}],"text":"Section M: Skin Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-13/M0210","prefix":"M0210","text":"Unhealed Pressure Ulcers/Injuries. Does this {patient/resident} have one or more unhealed pressure ulcers/injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.11.item.0"},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"Number of Stage 2 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.1"},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"Number of Stage 3 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.2"},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"Number of Stage 4 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.3"},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.4"},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.5"},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.6"},{"linkId":"Section-13/M0300","prefix":"M0300","text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0"},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1"},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2"},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3"},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4"},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5"},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6"}],"id":"item.11.item.7"},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"Number of Stage 1 pressure injuries","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.8"}],"id":"item.11","description":"In Section M of the form, the patient's skin conditions are addressed."},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Unhealed Pressure Ulcers/Injuries. Does this {patient/resident} have one or more unhealed pressure ulcers/injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.11.item.0","description":"Does this patient or resident have one or more unhealed pressure ulcers or injuries?"},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"Number of Stage 2 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.1","description":"The patient has how many Stage 2 pressure ulcers?"},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"Number of Stage 3 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.2","description":"How many stage 3 pressure ulcers does the patient have?"},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"Number of Stage 4 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.3","description":"The patient has a certain number of Stage 4 pressure ulcers."},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.4","description":"How many unstageable pressure ulcers/injuries does the patient have due to a non-removable dressing/device?"},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.5","description":"How many unstageable pressure ulcers does the patient have due to coverage of the wound bed by slough and/or eschar?"},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.6","description":"The patient has a certain number of unstageable pressure injuries that present as deep tissue injury."},{"linkId":"Section-13/M0300","prefix":"M0300","text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0"},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1"},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2"},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3"},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4"},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5"},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6"}],"id":"item.11.item.7","description":"The form is asking for the current number of unhealed pressure ulcers/injuries at each stage that the patient has."},{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0","description":"The patient's condition is at Stage 1, where there is intact skin with non-blanchable redness of a localized area, usually over a bony prominence. It is noted that darkly pigmented skin may not exhibit visible blanching. In such cases, dark skin tones may only appear with persistent blue or purple hues."},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1","description":"The patient is at stage 2, which indicates a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. This may also present as an intact or open/ruptured blister."},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2","description":"The patient is at stage 3, which indicates full thickness tissue loss. At this stage, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but it does not obscure the depth of tissue loss. This stage may also include undermining and tunneling."},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3","description":"The patient has stage 4 skin integrity, characterized by full thickness tissue loss with exposed bone, tendon, or muscle. There may be slough or eschar present on some parts of the wound bed, and the condition often includes undermining and tunneling."},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4","description":"The patient has an unstageable condition due to a non-removable dressing or device, although the exact stage is known but cannot be identified because of the non-removable dressing or device."},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5","description":"The patient has a known, but unstageable wound due to the coverage of the wound bed by slough and/or eschar."},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6","description":"The patient has an unstageable deep tissue injury."},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"Number of Stage 1 pressure injuries","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.8","description":"How many Stage 1 pressure injuries does the patient have?"},{"linkId":"Section-14","code":[{"system":"http://loinc.org","code":"88872-7","display":"IRF-PAI v2.0 - Medications - admission [CMS Assessment]"}],"text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/N2001","prefix":"N2001","text":"Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}],"id":"item.12.item.0"},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Medication Follow-up. Did the {facility/setting} contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.12.item.1"}],"id":"item.12","description":"In Section N of the form, the medications that the patient is currently taking are listed."},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}],"id":"item.12.item.0","description":"Did a complete drug regimen review identify any potential clinically significant medication issues for the patient? The options are 'Yes', 'No', and 'Not applicable'."},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Medication Follow-up. Did the {facility/setting} contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.12.item.1","description":"Did the facility or setting in question contact a physician or a physician's designee by midnight of the following calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues related to the patient?"},{"linkId":"Section-15","code":[{"system":"http://loinc.org","code":"83261-8","display":"IRF-PAI v3.0 - Special treatments, procedures, and programs - admission [CMS Assessment]"}],"text":"Section O: Special Treatments, Procedures, and Programs","type":"group","readOnly":true,"item":[{"linkId":"Section-15/O0100","prefix":"O0100","text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that were performed","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}],"id":"item.13.item.0"}],"id":"item.13","description":"In Section O of the form, the patient is asked about special treatments, procedures, and programs they may have undergone."},{"linkId":"Section-15/O0100","prefix":"O0100","text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that were performed","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}],"id":"item.13.item.0","description":"Please indicate all of the special treatments, procedures, and programs that were performed on the patient."},{"linkId":"Section-19","text":"Section Z: Assessment Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-19/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0"},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1"},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2"},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3"},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4"},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5"},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6"},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7"},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8"},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9"},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10"},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11"}],"id":"item.14.item.0"}],"id":"item.14","description":"In Section Z of the form, the assessment administration for the patient is carried out."},{"linkId":"Section-19/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0"},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1"},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2"},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3"},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4"},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5"},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6"},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7"},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8"},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9"},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10"},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11"}],"id":"item.14.item.0","description":"The signature of the person who completed the assessment for the patient is required."},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0","description":"The patient filled out the Signature, Title, Sections, and Date Section Completed A on the form."},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1","description":"The patient needs to provide their signature, title, and date for the sections they have completed in Section B."},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2","description":"The patient needs to complete the signature, title, and sections of the form, and indicate the date the section C was completed."},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3","description":"The patient is required to provide their signature, title, and date the sections that have been completed in Section D."},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4","description":"The patient needs to provide their signature, title, and the sections they have completed, along with the date they finished section E."},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5","description":"The patient's form contains a section for the signature, title, and sections, and also records the date the section was completed."},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6","description":"The patient is required to provide their signature, title, fill in the sections, and add the date the section was completed on form G."},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7","description":"The patient's form contains sections for signature, title, and date, which need to be completed. In section H, the form is completed."},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8","description":"The section titled \"Signature, Title, Sections, Date Section Completed I\" requires the patient's signature, their title, and the date on which they completed the section."},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9","description":"The patient completed the signature, title, and sections on the form, and dated it on section J."},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10","description":"The patient is required to provide their signature and title in the specified sections, and the date when they completed the form."},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11","description":"The patient must provide their signature and title, complete all sections, and include the date that they completed the form."},{"linkId":"Section-49","text":"Therapy Information","type":"group","readOnly":true,"item":[{"linkId":"Section-49/O0401","prefix":"O0401","text":"Week 1: total number of minutes provided","type":"text","repeats":false,"readOnly":false,"item":[{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0"}],"id":"item.15.item.0"}],"id":"item.15","description":"The patient's therapy information is required."},{"linkId":"Section-49/O0401","prefix":"O0401","text":"Week 1: total number of minutes provided","type":"text","repeats":false,"readOnly":false,"item":[{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0"}],"id":"item.15.item.0","description":"In the first week, what was the total number of minutes of care provided to the patient?"},{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0","description":"Does the patient require physical therapy?"},null],"_id":"BQwjK887hmvKS2e7p"} {"id":"fasi","responseType":"QuestionnaireResponse","status":"draft","authored":"2024-04-27T18:21:32.181Z","item":[{"linkId":"Section-37/GG0175A","prefix":"GG0175A","text":"Does the patient or resident use a manual wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0175F","prefix":"GG0175F","text":"Does the patient or resident use a motorized wheelchair and/or scooter?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0125B1","prefix":"GG0125B1","text":"Does the patient use an assistive device such as a standard folding walker?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170HH","prefix":"GG0170HH","text":"Does the patient or resident have the ability to walk?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No, and walking goal is not indicated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA31067-4","display":"No, and walking goal is not indicated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"No, and walking is indicated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA31068-2","display":"No, and walking goal is indicated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-6/F0900A1","prefix":"F0900A1","text":"Please identify the usual living arrangement of the patient or resident during the past three days.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident} lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30925-4","display":"Person lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident} lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30926-2","display":"Person lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident} lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30927-0","display":"Person lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident} does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30928-8","display":"Person does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident} was in a medical facility."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30929-6","display":"Person was in a medical facility."}}]},{"linkId":"Section-37/GG0125B","prefix":"GG0125B","text":"Does the patient use an assistive device such as a walker?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Z","prefix":"GG0125Z","text":"Does the patient use an assistive device other than the ones previously mentioned?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125A","prefix":"GG0125A","text":"The patient uses an assistive device, specifically a cane or a crutch.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125AA","prefix":"GG0125AA","text":"In the past month, has the patient used, or expressed or demonstrated a need for an assistive device?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}}]},{"linkId":"Section-6/F0910A","prefix":"F0910A","text":"Does the patient or resident have assistance in their home? The options are \"Yes\" or \"No\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170X7","prefix":"GG0170X7","text":"The patient's usual performance indicates their ability to walk across a street before the light turns red.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170E7","prefix":"GG0170E7","text":"The form inquires about the patient's usual performance in terms of their ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170J7","prefix":"GG0170J7","text":"Does the patient have the ability, once standing, to walk at least 50 feet and make two turns as part of their usual performance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920E1","prefix":"F0920E1","text":"Has the patient paid for medical procedures or treatments, such as changing wound dressings or home exercise programs?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920B2","prefix":"F0920B2","text":"Does the patient require mobility assistance, such as help with bed mobility, transfers, ambulating, or wheeling, and is this assistance unpaid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170K7","prefix":"GG0170K7","text":"Once the patient is standing, they should have the ability to walk at least 150 feet in a corridor or similar space. The usual performance is evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170F8","prefix":"GG0170F8","text":"The form inquires about the patient's ability to transfer to and from a toilet or commode, asking whether their performance is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170D7","prefix":"GG0170D7","text":"Does the patient typically have the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920H1","prefix":"F0920H1","text":"Does the individual advocate or facilitate the patient's participation in appropriate medical care, for example, providing transportation to or from appointments? The options for this are either paid or unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170M7","prefix":"GG0170M7","text":"The form asks about the patient's usual performance in the ability to go up and down a curb and/or up and down one step.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170W8","prefix":"GG0170W8","text":"The patient's ability to walk for 15 minutes without stopping or resting, like through a department store or supermarket, is the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170B7","prefix":"GG0170B7","text":"The form asks about the patient's usual ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130F7","prefix":"GG0130F7","text":"The form asks about the patient's usual performance in terms of their ability to dress and undress their upper body, including handling fasteners if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170X8","prefix":"GG0170X8","text":"The form asks the patient about their ability to walk across a street before the light turns red, with the most dependent performance as an answer choice.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170N7","prefix":"GG0170N7","text":"The form is asking about the patient's usual performance in regards to their ability to go up and down four steps, with or without using a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175B8","prefix":"GG0175B8","text":"Once seated in their manual wheelchair, the patient has the ability to wheel at least 50 feet and make two turns, indicating a most dependent performance level.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920F1","prefix":"F0920F1","text":"Does the patient manage their equipment, for example, oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies, and is it paid for?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920D2","prefix":"F0920D2","text":"Does the patient administer their medication themselves (for example, oral, inhaled, or injectable medications) without any paid assistance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0910B2","prefix":"F0910B2","text":"Please indicate the level of both paid and unpaid assistance in the patient's or resident's home during the past month. The level of assistance was unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No assistance received"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12345-7","display":"No assistance received"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Occasional/short-term assistance"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30934-6","display":"Occasional/short term assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Regular night-time"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30935-3","display":"Regular night-time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Regular daytime"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12164-2","display":"Regular daytime"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Around the clock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12163-4","display":"Around the clock"}}]},{"linkId":"Section-37/GG0130H7","prefix":"GG0130H7","text":"The form asks the patient to evaluate their usual performance in putting on and taking off socks, shoes, or other footwear appropriate for safe mobility. This includes handling fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170O8","prefix":"GG0170O8","text":"The form asks the patient to assess their ability to go up and down 12 steps with or without a rail, with the most dependent performance being the possible response.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130G7","prefix":"GG0130G7","text":"The form asks about the patient's usual performance in their ability to dress and undress below the waist, including fasteners, excluding footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170M8","prefix":"GG0170M8","text":"The form asks about the patient's ability to go up and down a curb and/or up and down one step. The patient's performance is most dependent in this activity.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175G8","prefix":"GG0175G8","text":"Once seated in their motorized wheelchair or scooter, the patient has the ability to wheel at least 50 feet and make two turns. However, their performance indicates that they are most dependent on this form of mobility.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920H2","prefix":"F0920H2","text":"Does the person facilitate or advocate for the patient's participation in appropriate medical care, for instance, by transporting them to or from appointments, without any charge?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0910B1","prefix":"F0910B1","text":"Please indicate the level of both paid and unpaid assistance in the patient's or resident's home during the past month. The choices are \"Paid\", \"Unpaid\", or \"Both Paid and Unpaid\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No assistance received"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12345-7","display":"No assistance received"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Occasional/short-term assistance"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30934-6","display":"Occasional/short term assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Regular night-time"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30935-3","display":"Regular night-time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Regular daytime"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12164-2","display":"Regular daytime"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Around the clock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12163-4","display":"Around the clock"}}]},{"linkId":"Section-37/GG0175B7","prefix":"GG0175B7","text":"The form asks about the patient's ability to wheel at least 50 feet and make two turns once seated in a manual wheelchair, assessing their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170I7","prefix":"GG0170I7","text":"The form asks about the patient's usual performance in terms of their ability to walk at least 10 feet once standing, whether it be in a room, corridor, or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170L7","prefix":"GG0170L7","text":"The form asks about the patient's usual performance in the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, both indoors and outdoors.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170U8","prefix":"GG0170U8","text":"The form asks about the patient's ability to walk from one room to another, maneuver around furniture, and navigate other obstacles indoors. The label classifies the patient's performance as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175C8","prefix":"GG0175C8","text":"Once the patient is seated in the wheelchair, they should have the ability to wheel at least 150 feet in a corridor or similar space. The choices for this ability are with a manual wheelchair or indicating the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185F8","prefix":"GG0185F8","text":"The form asks about the patient's ability to answer a telephone call in their customary manner and maintain it for 1 minute or longer. This does not include getting to the phone. The label for the most dependent performance is used.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185K7","prefix":"GG0185K7","text":"The patient's usual performance in simple financial management includes the ability to complete financial transactions such as counting coins, verifying change for a single item transaction, writing a check, online/mobile bill pay, banking, or shopping.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175E7","prefix":"GG0175E7","text":"The form is asking about the patient's ability to wheel across a street using a manual wheelchair before the light turns red. The patient usually performs this task with their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130F8","prefix":"GG0130F8","text":"The form asks about the patient's ability to dress and undress above the waist, including dealing with fasteners if applicable, and the patient's most dependent performance is being evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175H7","prefix":"GG0175H7","text":"Once the patient is seated in the wheelchair or scooter, does he or she have the ability to wheel at least 150 feet in a corridor or similar space? The options are: Motorized Wheelchair/Scooter or Usual Performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170C7","prefix":"GG0170C7","text":"The form asks about the patient's usual performance in the ability to move from lying on their back to sitting on the side of the bed with their feet flat on the floor, and without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130G8","prefix":"GG0130G8","text":"The form asks about the patient's ability to dress and undress below the waist, including handling fasteners, but not including footwear. It indicates that the patient's performance in this area is mostly dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130D8","prefix":"GG0130D8","text":"The form asks about the patient's ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed. The performance level indicated is \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170K8","prefix":"GG0170K8","text":"The form asks if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The performance level is gauged as 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185E8","prefix":"GG0185E8","text":"The patient's performance level in light shopping is at its most dependent. Once at the store, they can locate and select up to five needed goods, take them to the checkout, and complete the purchasing transaction.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170W7","prefix":"GG0170W7","text":"Does the patient have the ability to walk for 15 minutes without stopping or resting, such as through a department store or supermarket, as part of their usual performance?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170V7","prefix":"GG0170V7","text":"The form asks whether the patient has the ability to carry something in both hands, such as several dishes, a light laundry basket, or a tray with food, while walking indoors. The category for this question is 'Usual Performance.'","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170D8","prefix":"GG0170D8","text":"The form asks about the patient's ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. The patient's performance is most dependent in this regard.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920A2","prefix":"F0920A2","text":"Does the patient require unpaid assistance with self-care tasks such as bathing, dressing, toileting, or eating/feeding?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185G7","prefix":"GG0185G7","text":"The question on the form asks about the patient's or resident's usual performance in terms of the ability to place a call in their customary manner and maintain it for 1 minute or longer. Note that this does not include the act of getting to the phone.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185J7","prefix":"GG0185J7","text":"The patient's usual performance in medication management of injectable medications assesses their ability to prepare and take all prescribed injectable medications reliably and safely. This includes the administration of the correct dosage at the appropriate times or intervals.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170C8","prefix":"GG0170C8","text":"The form is asking about the patient's ability to move from lying on their back to sitting on the side of the bed with their feet flat on the floor, without any back support. The patient's performance in this task is categorized as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175J7","prefix":"GG0175J7","text":"The form asks the patient about their ability to wheel across a street before the light turns red once they are seated in a wheelchair or scooter. The options for response are 'Motorized Wheelchair/Scooter' and 'Usual Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185D7","prefix":"GG0185D7","text":"The patient's usual performance in the ability to complete heavier periodic housework, such as doing laundry, vacuuming, and cleaning the bathroom, is evaluated to ensure they can maintain a safe home environment and not be at risk for harm within their home.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185A8","prefix":"GG0185A8","text":"The form inquires about the patient's ability to plan and prepare all aspects of a light cold meal, such as a bowl of cereal, sandwich and cold drink. The patient's performance in this area is marked as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175G7","prefix":"GG0175G7","text":"Once the patient is seated in a wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. The options are either using a motorized wheelchair/scooter or executing their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170O7","prefix":"GG0170O7","text":"The patient's usual performance is their ability to go up and down 12 steps with or without a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175D8","prefix":"GG0175D8","text":"The patient's ability to wheel for 15 minutes once seated in a manual wheelchair, without stopping or resting, for example, through a department store or supermarket, is evaluated as the most dependent performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185H8","prefix":"GG0185H8","text":"The form is asking about the patient's ability to manage their oral medications. This involves the preparation and safely taking all prescribed oral medications, including the administration of the correct dosage at the appropriate times/intervals. The level of performance is marked as \"most dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125F","prefix":"GG0125F","text":"Does the patient use an assistive device such as a mechanical lift?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175D7","prefix":"GG0175D7","text":"The form asks if the patient has the ability to wheel without stopping or resting for 15 minutes once seated in a manual wheelchair, such as when navigating through a department store or supermarket. The question is about their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170G8","prefix":"GG0170G8","text":"The form asks about the patient's ability to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten the seat belt. The patient's performance in this area is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170I8","prefix":"GG0170I8","text":"The form asks about the patient's ability to walk at least 10 feet once they are standing, whether it be in a room, corridor, or a similar space. The patient's performance is rated as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0180B","prefix":"GG0180B","text":"Please ask the patient to describe at least one or two personal priorities in the area of mobility for the next six months. If the patient does not express any personal priorities in this area, please note this below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0130A7","prefix":"GG0130A7","text":"The form is asking about the patient's usual performance in eating. It refers to their ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185G8","prefix":"GG0185G8","text":"The form asks about the patient's or resident's ability to place a call in their customary manner and maintain it for 1 minute or longer. It does not include getting to the phone. The patient's performance in this area is classified as 'Most Dependent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175E8","prefix":"GG0175E8","text":"The form asks about the patient's ability to wheel across a street once seated in a wheelchair before the light turns red. The options are from most dependent to a manual wheelchair performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185B7","prefix":"GG0185B7","text":"The form asks whether the patient has the ability to plan and prepare all aspects of a light hot meal, such as heating a bowl of soup and reheating a prepared meal. The label for this question is referring to the patient's usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125L","prefix":"GG0125L","text":"Does the patient use an assistive device such as grab bars?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0905B","prefix":"F0905B","text":"Please ask the patient to describe at least one or two personal priorities in the area of living arrangements for the next six months. If the patient does not express any personal priorities in this area, kindly note this down.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170U7","prefix":"GG0170U7","text":"The form asks about the patient's usual performance in their ability to walk indoors, specifically from room to room, and around furniture and other obstacles.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185E7","prefix":"GG0185E7","text":"The form asks about the patient's usual performance in light shopping tasks. Specifically, it asks if the patient can once at the store locate and select up to five needed goods, take them to the checkout, and complete the purchasing transaction.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170P8","prefix":"GG0170P8","text":"The form inquires about the patient's ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor. The performance level selected for the patient is \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185B8","prefix":"GG0185B8","text":"The form asks about the patient's ability to plan and prepare all aspects of a light hot meal, such as heating a bowl of soup and reheating a prepared meal. It is noted that the patient's performance in this area is most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125Q","prefix":"GG0125Q","text":"Does the patient use an assistive device such as a hearing aid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125ZZ","prefix":"GG0125ZZ","text":"The patient has indicated all the assistive devices they needed.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-37/GG0170N8","prefix":"GG0170N8","text":"The form inquires about the patient's ability to go up and down four steps, with or without the assistance of a rail. The performance level was noted as \"most dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0900A2","prefix":"F0900A2","text":"Please identify the patient's or resident's usual living arrangement during the past month.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident} lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30925-4","display":"Person lives alone - no other residents in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident} lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30926-2","display":"Person lives with others in the home - for example, family, friends, or paid caregiver."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident} lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30927-0","display":"Person lives in congregate home - for example, assisted living, or residential care home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident} does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30928-8","display":"Person does not have a permanent home or is homeless."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident} was in a medical facility."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30929-6","display":"Person was in a medical facility."}}]},{"linkId":"Section-37/GG0170J8","prefix":"GG0170J8","text":"Once the patient is standing, they will be assessed on their ability to walk at least 50 feet and make two turns. The potential ratings for performance in this task range from 'Most Dependent' to 'Independent'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130EE7","prefix":"GG0130EE7","text":"The form inquires about the patient's usual performance regarding the ability to shower or bathe themselves, including tasks such as washing, rinsing, and drying themselves. It should be noted that this does not include the act of transferring in or out of the tub or shower.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185C7","prefix":"GG0185C7","text":"The form is asking about the patient's usual performance in terms of their ability to complete light daily housework. This entails maintaining a safe home environment so that the patient is not at risk from harm within their home. Examples of such housework include tasks like wiping counter tops or doing dishes.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130EE8","prefix":"GG0130EE8","text":"The form is asking about the patient's level of ability to bathe themselves, including washing, rinsing, and drying. The question does not include the process of transferring in and out of a tub or shower. The performance level designated is \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920A1","prefix":"F0920A1","text":"Does the patient require paid assistance for self-care activities such as bathing, dressing, toileting, or eating/feeding?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0170E8","prefix":"GG0170E8","text":"The form asks about the patient's ability to transfer from a bed to a chair or wheelchair. It is labeled \"Most Dependent Performance\", indicating the need for assistance with this task.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125M","prefix":"GG0125M","text":"Does the patient use an assistive device such as a transfer board?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0130B8","prefix":"GG0130B8","text":"The form asks about the patient's ability to maintain oral hygiene by using suitable items to clean their teeth and, if applicable, their ability to insert and remove dentures into and from their mouth, as well as manage denture soaking and rinsing with the use of equipment. The response category for their performance is \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125S","prefix":"GG0125S","text":"The patient uses an assistive device, specifically stair rails.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0135B","prefix":"GG0135B","text":"Please ask the patient to describe at least one or two personal priorities in the area of self-care for the next six months. If the patient does not express any personal priorities in this area, please record this information below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170P7","prefix":"GG0170P7","text":"The form asks about the patient's usual performance in the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175C7","prefix":"GG0175C7","text":"Once the patient is seated in their manual wheelchair, their usual performance indicates their ability to wheel at least 150 feet in a corridor or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920E2","prefix":"F0920E2","text":"The patient has undergone medical procedures/treatments such as changing a wound dressing or a home exercise program, for which they have not paid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185K8","prefix":"GG0185K8","text":"The form asks about the patient's simple financial management skills, such as their ability to complete financial transactions, counting coins, verifying change for a single item transaction, writing a check, using online/mobile bill pay, banking, or shopping. The patient's performance is most dependent in these areas.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125C","prefix":"GG0125C","text":"Does the patient use an assistive device such as a wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185H7","prefix":"GG0185H7","text":"The patient's usual performance in medication management, specifically for oral medications, refers to their ability to prepare and take all prescribed oral medications reliably and safely. This includes administering the correct dosage at the appropriate times or intervals.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125P","prefix":"GG0125P","text":"Does the patient use an assistive device such as glasses or contact lenses?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175I7","prefix":"GG0175I7","text":"The form asks about the patient's ability to wheel for 15 minutes without stopping or resting, such as through a department store or supermarket, while seated in a wheelchair or scooter. Does the patient typically use a motorized wheelchair or scooter for this task?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125W","prefix":"GG0125W","text":"Does the patient use an assistive device such as a glucometer?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125T","prefix":"GG0125T","text":"Does the patient use an assistive device such as a lift chair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125D","prefix":"GG0125D","text":"Does the patient use an assistive device such as a limb prosthesis?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185J8","prefix":"GG0185J8","text":"The form asks about the patient's ability to manage injectable medications. It specifically addresses whether the patient can reliably and safely prepare and take all prescribed injectable medications, including the administration of the correct dosage at the correct times/intervals. The patient's performance in this area is marked as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125V","prefix":"GG0125V","text":"Does the patient use an assistive device such as a raised toilet seat?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Y","prefix":"GG0125Y","text":"Does the patient use an assistive device such as an oxygen concentrator?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0175J8","prefix":"GG0175J8","text":"The question on the form is asking about the patient's ability, once seated in a wheelchair or scooter, to wheel across a street before the traffic light turns red. The answer choices are 'Motorized Wheelchair/Scooter' and 'Most Dependent Performance.'","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185I7","prefix":"GG0185I7","text":"The form asks about the patient's ability to manage their medication, specifically regarding inhalant or mist medications. It wants to know if the patient can prepare and take all prescribed inhalant or mist medications reliably and safely, including the correct dosage at the appropriate times or intervals. It asks for information about their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125U","prefix":"GG0125U","text":"Does the patient use an assistive device such as ramps?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0180A","prefix":"GG0180A","text":"Please ask the patient to describe at least one or two personal priorities in the area of mobility for the next six months. If the patient does not express any personal priorities in this area, please note this below. The answer options would be: A) Improvement in walking, B) Ability to climb stairs, C) Independence in moving, or D) No personal priorities.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0135A","prefix":"GG0135A","text":"Please ask the patient to describe at least one or two personal priorities in the area of self-care for the next six months. If the patient does not express any personal priorities in this area, please note this in their record.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0125K","prefix":"GG0125K","text":"Does the patient use an assistive device such as an electronic bed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125H","prefix":"GG0125H","text":"Does the patient use an assistive device such as a sock aid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920C2","prefix":"F0920C2","text":"The patient requires assistance with Instrumental Activities of Daily Living (IADL), such as making meals, housekeeping, telephone, shopping, or finances, which is currently unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0130A8","prefix":"GG0130A8","text":"The question on the form assesses the patient's ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them. The performance options range from independent to most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125J","prefix":"GG0125J","text":"Does the patient use an assistive device such as a bed rail?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920G1","prefix":"F0920G1","text":"Does the patient require supervision, for example due to safety concerns, and is this supervision paid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0125O","prefix":"GG0125O","text":"Does the patient use an assistive device such as a walk-in or wheel-in shower?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125B3","prefix":"GG0125B3","text":"Does the patient use an assistive device, specifically a walker with wheels?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125G","prefix":"GG0125G","text":"Does the patient use an assistive device such as a reacher or grabber?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170F7","prefix":"GG0170F7","text":"The form asks about the patient's usual performance in terms of their ability to get on and off a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125N","prefix":"GG0125N","text":"Does the patient require an assistive device such as a shower or commode chair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125X","prefix":"GG0125X","text":"Does the patient use an assistive device such as a Continuous Positive Airway Pressure (CPAP) machine?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125C1","prefix":"GG0125C1","text":"Does the patient use an assistive device such as a manual wheelchair?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170G7","prefix":"GG0170G7","text":"The patient's usual performance indicates their ability to transfer in and out of a car or van on the passenger side. This does not include their ability to open/close the door or fasten the seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125B2","prefix":"GG0125B2","text":"Does the patient use an assistive device such as a walker with a seat?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0185I8","prefix":"GG0185I8","text":"The form asks about the patient's ability to manage medication, specifically inhalant or mist medications. It wants to know if the patient can reliably and safely prepare and take all prescribed inhalant/mist medications, including the administration of the correct dosage at the appropriate times and intervals. The answer choices include 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130B7","prefix":"GG0130B7","text":"The form asks about the patient's oral hygiene, specifically their ability to use suitable items to clean their teeth. It also inquires about their use of dentures, if applicable, including their ability to insert and remove the dentures from their mouth, and manage denture soaking and rinsing with the use of equipment. The section is labeled \"Usual Performance.\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125I","prefix":"GG0125I","text":"Does the patient use an assistive device such as orthotics or a brace?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125Z_specify","prefix":"GG0125Z_specify","text":"Does the patient use any other type of assistive device? If so, please specify.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170A8","prefix":"GG0170A8","text":"The patient's ability to roll from lying on their back to their left and right side, and return to lying on their back is most dependent on performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130CC7","prefix":"GG0130CC7","text":"The form asks about the patient's usual performance in maintaining toileting hygiene, specifically their ability to maintain perineal/menstrual hygiene and adjust clothing before and after voiding or having a bowel movement. If the patient manages an ostomy, it also includes wiping the opening but does not include managing equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920D1","prefix":"F0920D1","text":"The form asks about the patient's method of medication administration, with options that include oral, inhaled, or injectable medications. The medication administration for the patient is paid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0125E","prefix":"GG0125E","text":"Does the patient use an assistive device, such as a specialized seating pad (for example, an air-filled, gel, or shaped form pad)?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0125C2","prefix":"GG0125C2","text":"Does the patient use an assistive device such as a motorized wheelchair and/or scooter?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-37/GG0170L8","prefix":"GG0170L8","text":"The form asks whether the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoors or outdoors. The answer choices for the patient's performance are: Most Independent Performance, Modified Independent, Supervision or Setup, Minimal Assistance, Moderate Assistance, Maximal Assistance, and Most Dependent Performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130CC8","prefix":"GG0130CC8","text":"The form asks the patient about their toileting hygiene, specifically their ability to maintain perineal/menstrual hygiene and adjust their clothes before and after voiding or having a bowel movement. If they are managing an ostomy, they should include their ability to wipe the opening, although managing the equipment is not necessary. The performance rating is either \"Most Dependent Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185A7","prefix":"GG0185A7","text":"The patient's usual performance demonstrates the ability to plan and prepare all aspects of a light, cold meal such as a bowl of cereal, sandwich, and cold drink.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-6/F0920G2","prefix":"F0920G2","text":"The form asks if the patient requires supervision due to safety concerns, and specifies if this supervision is unpaid.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-6/F0920C1","prefix":"F0920C1","text":"Does the patient require paid assistance for Instrumental Activities of Daily Living (IADL), such as making meals, housekeeping, using the telephone, shopping, or managing finances?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185L7","prefix":"GG0185L7","text":"The patient's usual performance in complex financial management involves the ability to complete financial decision-making tasks such as budgeting and remembering to pay bills.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185C8","prefix":"GG0185C8","text":"The form inquires about the patient's ability to perform light daily housework in order to maintain a safe home environment such that they are not at risk from harm within their own home. Examples of this housework might include tasks like wiping countertops or doing dishes. The patient's performance is labeled as \"Most Dependent\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0125R","prefix":"GG0125R","text":"Does the patient use an assistive device such as a communication device?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Assistive device needed and available - {Patient/Resident} needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30918-9","display":"Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets {patient's/resident's} needs."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30919-7","display":"Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistive device needed but not available - {Patient/Resident} needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30920-5","display":"Assistive device needed but not available - Person needs the device but it is not available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused - {Patient/Resident} chooses not to use needed device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30921-3","display":"Person refused - Person chooses to not use needed device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not need this device."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30922-1","display":"Not applicable - Person does not need this device."}}]},{"linkId":"Section-6/F0920F2","prefix":"F0920F2","text":"Does the patient manage their own equipment, such as oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies, without any payment?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185D8","prefix":"GG0185D8","text":"The form asks about the patient's ability to complete heavier periodic housework, like doing laundry, vacuuming, and cleaning the bathroom, in order to maintain a safe home environment. It also ensures the patient is not at risk for harm within their home. The category marked is 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170B8","prefix":"GG0170B8","text":"The form for the patient includes a question labeled \"Sit to lying\". This refers to the patient's ability to move from sitting on the side of the bed to lying flat on the bed. The performance is categorized as \"Most Dependent\", meaning the patient requires substantial assistance in this task.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130D7","prefix":"GG0130D7","text":"Does the patient have the ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed? Please rate their usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0190A","prefix":"GG0190A","text":"Please ask the patient to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the patient does not express any personal priorities in this area, please note this below. Answer: A","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0905A","prefix":"F0905A","text":"Please ask the patient to describe at least one or two personal priorities in the area of their living arrangements for the next six months. If the patient does not express any personal priorities in this area, please note this below. The options are - A.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0920B1","prefix":"F0920B1","text":"Does the patient require mobility assistance, such as assistance with bed mobility, transfers, ambulating, or wheeling? If yes, is this assistance paid?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30938-7","display":"Assistance not needed - No assistance needed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Caregiver(s) currently provide assistance - {Patient's/Resident's} usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30939-5","display":"Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30940-3","display":"Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unclear is caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30941-1","display":"Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Assistance needed but no caregiver(s) available - {Patient/Resident} needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30942-9","display":"Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home."}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Assistance needed but {patient/resident} declines assistance - {Patient/Resident} needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30943-7","display":"Assistance needed but person declines assistance - Person needs caregiving but declines this assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30944-5","display":"Not applicable - Person does not do this activity."}}]},{"linkId":"Section-37/GG0185L8","prefix":"GG0185L8","text":"The form indicates the patient's level of ability in complex financial management, such as completing financial decision-making tasks including budgeting and remembering to pay bills. The patient's performance is recorded as mostly dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0130H8","prefix":"GG0130H8","text":"The form asks about the patient's ability to put on and take off socks, shoes, or other appropriate footwear that is necessary for safe mobility, which includes dealing with fasteners, if applicable. The patient's performance in this aspect has been rated as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175H8","prefix":"GG0175H8","text":"The form is asking about the patient's ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter. The answer choices include 'Motorized Wheelchair/Scooter' and 'Most Dependent Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0170A7","prefix":"GG0170A7","text":"The form asks about the patient's usual performance when it comes to their ability to roll from lying on their back to their left and right side, and then return to lying on their back.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0185F7","prefix":"GG0185F7","text":"The form asks about the patient's ability to answer a telephone call in their customary manner and maintain the call for one minute or longer. It does not include getting to the phone. The question refers to the patient's usual performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0175I8","prefix":"GG0175I8","text":"The patient questionnaire asked, \"Once the patient is seated in a wheelchair or scooter, do they have the ability to wheel without stopping or resting for 15 minutes (for example, through a department store or supermarket)?\" The answer choices include \"Motorized Wheelchair/Scooter\" and \"Most Dependent Performance.\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]},{"linkId":"Section-37/GG0190B","prefix":"GG0190B","text":"Please ask the patient to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the patient does not express any personal priorities in this area, note it below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0925A","prefix":"F0925A","text":"Please ask the patient to describe at least one or two personal priorities for their caregiving arrangement in the next six months. If the patient does not express any personal priorities in this area, please note this below.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-6/F0925B","prefix":"F0925B","text":"Please ask the patient or resident to describe at least one or two personal priorities in the area of caregiving for the next six months. If the patient or resident does not express any personal priorities in this area, please note this below. The options are:\n\nA. The patient expresses personal priorities in the area of caregiving.\nB. The patient does not express any personal priorities in the area of caregiving.","type":"text","repeats":false,"readOnly":false,"maxLength":1500},{"linkId":"Section-37/GG0170V8","prefix":"GG0170V8","text":"The form for the patient asks about his or her ability to carry something in both hands while walking indoors, such as several dishes, a light laundry basket, or a tray with food. The patient's performance in this area is identified as most dependent.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30909-8","display":"Independent - Person completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30910-6","display":"Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30911-4","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30914-8","display":"Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA30915-5","display":"Person refused."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident} does not usually do this activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30916-3","display":"Not applicable - Person does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns."}},{"valueCoding":{"system":"http://loinc.org","code":"LA30917-1","display":"Not attempted due to short-term medical condition or safety concerns."}}]}],"_id":"oEaEhcHDPrfTb5cQu"} {"responseType":"QuestionnaireResponse","id":"his-ha-2.00.0","questionnaire":"HIS-HA-2.00.0","title":"Hospice Item Set - Hospice Admission Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-04-27T18:38:55.449Z","item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"The form asks for the patient's Medicaid number. The patient should enter \"+\" if their Medicaid status is pending, or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-36/A0800","prefix":"A0800","text":"What is the patient's gender? The possible answers could be male, female, or prefer not to say.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record for the patient needs to be specified.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0250","prefix":"A0250","text":"The reason for the patient's assessment needs to be determined.","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"What is the patient's admission date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Where was the patient immediately preceding this admission? Was the patient admitted from another hospital, a nursing home, their residence, or another location?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0550","prefix":"A0550","text":"What is the patient's ZIP code?","type":"text","repeats":false,"readOnly":false,"maxLength":11},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"Does the patient have a National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"What is the patient's CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"The form asks for the patient's suffix.","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A1000","prefix":"A1000","text":"The patient should check all the applicable boxes for their race or ethnicity.","type":"text","repeats":true,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A1400","prefix":"A1400","text":"The patient needs to fill out the payer information and must check all the options that apply to them.","type":"text","repeats":true,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0205","prefix":"A0205","text":"What was the site of service at the patient's admission?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0245","prefix":"A0245","text":"The date when the initial nursing assessment was initiated for the patient.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the patient, resident, or responsible party asked about their preference regarding the use of cardiopulmonary resuscitation (CPR)? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"The date on which the patient or responsible party was first asked about their preference regarding the use of CPR.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the patient, or their responsible party, asked about their preferences regarding life-sustaining treatments other than CPR? Select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"What was the date when the patient or responsible party was first asked about their preferences regarding life-sustaining treatments other than CPR?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the patient or the responsible party asked about their preference regarding hospitalization? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"The date when the patient, resident, or responsible party was first asked about their preference regarding hospitalization is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the patient or their caregiver asked about any spiritual or existential concerns? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"The date on which the patient or caregiver was first asked about spiritual or existential concerns is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-9/I0010","prefix":"I0010","text":"What is the patient's principal diagnosis?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the patient or resident screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"The date of the patient's first screening for pain was:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The severity of the patient's or resident's pain was:","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"What type of standardized pain tool was used for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Is pain an active problem for the patient or resident?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment conducted on the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"When was the patient's comprehensive pain assessment conducted?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"A comprehensive pain assessment was included for the patient where they needed to check all applicable options.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the patient or resident screened for any symptoms of shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"The date of the patient's first screening for shortness of breath was:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate that the patient had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"The form asks if treatment for the patient's shortness of breath was initiated. Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"What is the date when the treatment for shortness of breath was initiated for the patient?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"What types of treatment for shortness of breath have been initiated for the patient? Please check all that apply.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"The date the patient had their opioid treatment initiated or continued is scheduled for:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid medication initiated or continued for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"The date on which the patient's PRN opioid was initiated or continued is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued for the patient? Please select the most accurate response.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"The date on which the patient's bowel regimen was initiated or continued is:","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"The patient must provide their signature and title, as well as complete section A, including the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"The patient is required to provide their signature, title, and date they completed section B.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"The patient needs to provide their signature, title, and date on the completed C section of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"The patient needs to provide their signature, title, and the date on which they completed Section D of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"The patient needs to provide their signature, title, and the sections completed, along with the date when section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"The patient must sign, provide their title, complete all sections of the form, and include the date that each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"The patient needs to provide their signature and title, fill out the necessary sections, and date the section when it's completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"The patient is required to provide their signature, title, and the date they completed Section H on the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"The patient needs to provide their signature, title, and the date they completed section I.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title, complete the sections, and include the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature and title, and complete the sections indicated on the form. The date the section was completed should also be included.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"The patient's form must include their signature and title, the sections filled out, as well as the date each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"The patient needs to provide their signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"The date on which the RN Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false}],"_id":"aGNrrH6LQbbXinsbA"} {"responseType":"QuestionnaireResponse","id":"his-hd-2.00.0","questionnaire":"HIS-HD-2.00.0","title":"Hospice Item Set - Hospice Discharge Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-04-27T18:40:14.338Z","item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"The patient is required to enter a \"+\" if their Medicaid Number is pending or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-36/A0800","prefix":"A0800","text":"The patient's gender is being asked, with the answer choices being male, female, or prefer not to say.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record pertaining to the patient needs to be identified.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0250","prefix":"A0250","text":"What is the reason for the patient's assessment?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"The admission date of the patient is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0270","prefix":"A0270","text":"What is the patient's discharge date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"What is the patient's National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"What is the patient's CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"What is the patient's suffix?","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A2115","prefix":"A2115","text":"What was the patient's reason for discharge?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final three days of their life?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Did a registered nurse visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"The registered nurse visited the patient one day prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"The patient was visited by a registered nurse two days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant one day prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Did the patient visit a physician, nurse practitioner, or physician assistant two days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"The medical social worker visited the patient on the day of their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"The medical social worker visited the patient one day prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"The medical social worker visited the patient two days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Did the patient receive a visit from a chaplain or spiritual counselor on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Did the patient receive a visit from a chaplain or spiritual counselor one day prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Did the patient receive a visit from a Chaplain or Spiritual Counselor two days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Did the Licensed Professional Nurse visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Did the licensed professional nurse visit the patient one day prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Did the Licensed Professional Nurse visit the patient two days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Did an aide visit the patient on the day of their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Did the aide visit the patient one day prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Did the aide visit the patient two days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final seven days of their life? This question refers to the level of care given in the final seven days.","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"The patient was visited by a registered nurse three days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"The registered nurse visited the patient four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"The registered nurse visited the patient five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"The registered nurse visited the patient six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Did the patient visit a physician, nurse practitioner, or physician assistant three days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Did the patient visit a physician, nurse practitioner, or physician assistant four days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"The patient was visited by a physician, nurse practitioner, or physician assistant five days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Did the patient visit a physician, nurse practitioner, or physician assistant six days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Did the medical social worker visit the patient three days prior to their death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"The medical social worker visited the patient four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"The medical social worker visited the patient five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"The medical social worker visited the patient six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Did the patient have a visit from a chaplain or spiritual counselor three days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"The patient's chaplain or spiritual counselor visited four days prior to death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"The patient was visited by a Chaplain or Spiritual Counselor five days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Did the patient receive a visit from a chaplain or spiritual counselor six days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"The patient was visited by a Licensed Professional Nurse three days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"The patient was visited by a Licensed Professional Nurse four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Did the licensed professional nurse visit the patient five days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"The patient was visited by a Licensed Professional Nurse six days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Did the aide visit the patient three days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"The patient received visits from the aide four days prior to their death.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Did the aide visit the patient five days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Did the aide visit the patient six days prior to death?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"The patient is required to provide their signature and title, and to acknowledge the sections and date that the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"The patient is required to provide their signature, title, and the date on which they completed Section B.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"The patient is asked to provide their signature and title in the designated sections, and to also indicate the date when the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"The form for the patient asks for the patient's signature, their title, the sections they have completed, and the date they completed section D.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"The section indicated as \"Signature, Title, Sections, Date Section Completed E\" on the patient's form needs to be filled out.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"The patient's signature, title, and the date of completion are required in section F.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"The patient is required to provide their signature and title in the designated sections and indicate the date when they completed Section G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"The patient's form includes sections for signature, title, and date of completion, all of which must be filled out by Section H.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"The patient must provide their signature, title, date, and completed sections in section I.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title, and complete sections J of the form. This needs to be done by a specific date.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"The sections, signature, title, and the date when the section was completed are required information for patient K's form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"The sections of the form, including the signature, title, and date section, were completed by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"The form requires the patient's signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"The date on which the RN Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false}],"_id":"Dndh3Mbj6F8q8ZDPd"} {"responseType":"QuestionnaireResponse","id":"irf-pai-ia-3.0","questionnaire":"IRF-PAI-IA-3.0","title":"Inpatient Rehabilitation Facility Patient Assessment Instrument - IRF Admission","description":"Assessment data collected on all Medicare Part A fee-for-service patients who receive services under Part A from an inpatient rehabilitation facility (IRF) at admission and upon discharge.","status":"draft","authored":"2024-04-27T18:34:15.837Z","item":[{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-38/A0700","prefix":"A0700","text":"The patient should enter a \"+\" in the Medicaid Number field if the application is pending, or \"N\" if they are not a Medicaid recipient.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-38/A0800","prefix":"A0800","text":"The patient's gender is required. Is the patient male or female?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Male"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Female"}}]},{"linkId":"Section-38/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/A1200","prefix":"A1200","text":"What is the patient's marital status? Is he/she single, married, divorced, separated, or widowed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Never married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Widowed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Separated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Divorced"}}]},{"linkId":"Section-38/A0220","prefix":"A0220","text":"What is the admission date for the patient?","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/11","prefix":"11","text":"What is the zip code of the patient's or resident's pre-hospital residence?","type":"text","repeats":false,"readOnly":false,"maxLength":5},{"linkId":"Section-38/13","prefix":"13","text":"The assessment reference date for the patient has been set.","type":"date","repeats":false,"readOnly":false},{"linkId":"Section-38/14","prefix":"14","text":"The admission class of the patient is categorized under which category?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Initial Rehab"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Evaluation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Readmission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unplanned Discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Continuing Rehabilitation"}}]},{"linkId":"Section-38/17","prefix":"17","text":"Does the patient live at home prior to hospitalization? If the pre-hospital living setting is the patient's home, please code accordingly.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Alone"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Family / Relatives"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Friends"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Attendant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Other"}}]},{"linkId":"Section-38/15A","prefix":"15A","text":"From where was the patient admitted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}}]},{"linkId":"Section-38/16A","prefix":"16A","text":"The patient's pre-hospital living setting is required. Please use codes from the 'Admit From' category.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}}]},{"linkId":"Section-38/1A","prefix":"1A","text":"What is the name of the facility or provider for the patient?","type":"text","repeats":false,"readOnly":false,"maxLength":50},{"linkId":"Section-38/5B","prefix":"5B","text":"What is the patient's or resident's identification number?","type":"text","repeats":false,"readOnly":false,"maxLength":50},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Please check all the boxes that apply to the patient's race and ethnicity.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}]},{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Please record the most recent height measurement in inches for the patient since their admission.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"The patient's weight in pounds should be based on the most recent measure taken within the specified time period. The weight measurement must be executed consistently, adhering to the standard practice of the facility or setting, such as in the morning after voiding, before meals, with shoes off, etc.","type":"integer","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-41/21A","prefix":"21A","text":"The impairment group upon admission refers to the condition that required the patient to be admitted to rehabilitation; this should be coded according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-41/23","prefix":"23","text":"When did the impairment of the patient first begin?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Does the patient have any arthritis conditions recorded in either the impairment group, etiologic diagnosis, or comorbid conditions that meet all the regulatory requirements for Inpatient Rehabilitation Facility (IRF) classification?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-41/22A","prefix":"22A","text":"The form asks for the patient's etiologic diagnosis A.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/22B","prefix":"22B","text":"The form asks the patient for their etiologic diagnosis B.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/22C","prefix":"22C","text":"The form for the patient includes a section on etiologic diagnosis C.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24A","prefix":"24A","text":"Does the patient have Comorbid Condition A?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24B","prefix":"24B","text":"Does the patient have Comorbid Condition B?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24C","prefix":"24C","text":"Does the patient have Comorbid Condition C?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24D","prefix":"24D","text":"Does the patient have a comorbid condition D?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24E","prefix":"24E","text":"Does the patient have a comorbid condition E?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24F","prefix":"24F","text":"Does the patient have a comorbid condition F?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24G","prefix":"24G","text":"Does the patient have a comorbid condition G?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24H","prefix":"24H","text":"Does the patient have a comorbid condition H? Please select 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24I","prefix":"24I","text":"Does the patient have a comorbid condition? Please select either 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24J","prefix":"24J","text":"Does the patient have comorbid condition J?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24K","prefix":"24K","text":"Does the patient have a comorbid condition K?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24L","prefix":"24L","text":"Does the patient have any comorbid conditions? Please list them.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24M","prefix":"24M","text":"The patient has a comorbid condition labelled as M.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24N","prefix":"24N","text":"Does the patient have any comorbid conditions? Please select 'Yes' or 'No'.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24O","prefix":"24O","text":"Does the patient have any comorbid conditions?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24P","prefix":"24P","text":"Does the patient have a comorbid condition P?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Does the patient have a comorbid condition?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24R","prefix":"24R","text":"Does the patient have a comorbid condition R?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24S","prefix":"24S","text":"The form inquires about the patient's comorbid conditions.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24T","prefix":"24T","text":"Does the patient have a comorbid condition? Please choose one: Yes or No.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24U","prefix":"24U","text":"The patient has a comorbid condition, referred to as Condition U.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24V","prefix":"24V","text":"Does the patient have a comorbid condition V?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24W","prefix":"24W","text":"Does the patient have a comorbid condition W?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24X","prefix":"24X","text":"Does the patient have a comorbid condition X?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Does the patient have a comorbid condition labeled as Y?","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-40/20A","prefix":"20A","text":"The primary source of information about the patient is the patient themselves.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}]},{"linkId":"Section-40/20B","prefix":"20B","text":"The form asks the patient to provide a secondary source of information.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}]},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"The patient's ability to express ideas and wants, considering both verbal and non-verbal expression and excluding language barriers, is being evaluated.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}]},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Does the patient understand verbal and non-verbal content with the use of a hearing aid or device, excluding language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}]},{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should a brief interview for mental status be conducted? An attempt should be made to conduct an interview with all patients or residents.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-3/C0200","prefix":"C0200","text":"The form asks the patient: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" The form then records the number of words the patient repeated after the first attempt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}]},{"linkId":"Section-3/C0500","prefix":"C0500","text":"The BIMS Summary Score requires the addition of scores for the Brief Interview for Mental Status questions, with the total score filled in, ranging from 00-15. If the patient or resident was unable to complete the interview, enter 99.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the staff conduct an assessment for the patient's mental status?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}]},{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"The form asks the patient, \"Please tell me what year it is right now,\" to determine if they are able to accurately report the current year.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}]},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"The form asks the patient: \"What month are we in right now?\" The patient is expected to be able to report the correct month.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}]},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"The form asks the patient, \"What day of the week is today?\" The patient is then expected to be able to report the correct day of the week.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}]},{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"The patient is able to recall the word \"sock\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"The patient is able to recall the color \"blue\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Is the patient able to recall the word \"bed\"?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}]},{"linkId":"Section-3/C0900","prefix":"C0900","text":"The form asked to check all the items that the patient or resident was normally able to recall, indicating their memory or recall ability.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}]},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"The question on the form asks about the patient's ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them. This refers to their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"The patient's oral hygiene refers to their ability to use suitable items to clean their teeth. If applicable, their ability to handle dentures is evaluated by their capability to insert and remove them into and from the mouth, as well as successfully managing the soaking and rinsing of the dentures with the use of equipment. This is part of their admission performance assessment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"Does the patient have the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement? If the patient is managing an ostomy, does this include wiping the opening but not managing the equipment? Please assess their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"The discharge goal for the patient or resident is to gain the ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"The patient's oral hygiene pertains to their ability to use suitable items to clean their teeth. If applicable, their denture care involves the ability to insert and remove dentures into and from the mouth, as well as managing denture soaking and rinsing with the use of equipment. The discharge goal is to ensure these abilities.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"The discharge goal is for the patient to have the ability to maintain perineal hygiene, adjust their clothes before and after voiding or having a bowel movement. If they are managing an ostomy, this includes wiping the opening but not managing the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"The form asks about the patient's ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed during their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"The form asks about the patient's ability to move from sitting on the side of the bed to lying flat on the bed at the time of admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"The form asks about the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. This is referred to as 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"The discharge goal for the patient is to have the ability to roll from lying on their back to their left and right side, and then return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"The discharge goal for the patient includes the ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"The patient's discharge goal is the ability to move from lying on the back to sitting on the side of the bed without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"Does the patient have the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"The patient's admission performance includes the ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"The admission form poses a question regarding the patient's ability to transfer to and from a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"The question on the form asks about the patient's admission performance, specifically their ability to walk at least 10 feet in a room, corridor, or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"The form asks about the patient's admission performance, specifically their ability to walk at least 50 feet and make two turns once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"The form asks about the patient's admission performance, specifically, once standing, does the patient have the ability to walk at least 150 feet in a corridor or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"Once the patient is seated in the wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. This is a requirement for admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"The form asks about the patient's admission performance regarding their ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K3","prefix":"GG0170K3","text":"Does the patient have the ability, once standing, to walk at least 150 feet in a corridor or similar space? This will be evaluated as part of their discharge performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"The discharge goal for the patient is to develop the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"The discharge goal for the patient is to be able to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"The discharge goal for the patient is to have the ability to get on and off a toilet or commode independently.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"The discharge goal for the patient is to achieve the ability to walk at least 10 feet once standing, whether it's in a room, corridor, or similar space.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"The form asks if, once standing, the patient has the ability to walk at least 50 feet and make two turns. The answer options for this question are \"Yes\" or \"No\". This information will help set a discharge goal for the patient.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"The form inquires if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The goal is to attain this ability by the time of discharge.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"The discharge goal for the patient is to be able once seated in the wheelchair or scooter, to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"The discharge goal for the patient is to have the ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the patient or resident use a wheelchair and/or scooter upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Please indicate the type of wheelchair or scooter that the patient uses upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"The patient is required to indicate the type of wheelchair or scooter used upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"The form inquires about the patient's ability to bathe themselves, which includes washing, rinsing, and drying themselves, excluding washing of the back and hair. It does not consider the ability to transfer in or out of the tub or shower. This information is required for the Admission Performance assessment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"The admission performance form inquires about the patient's ability to dress and undress above the waist, including the handling of fasteners if applicable, under the section labeled 'Upper Body Dressing'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"On the admission form, it asks about the patient's ability to dress and undress below the waist, including handling fasteners. It does not include dealing with footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"The form asks about the patient's ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable. This is in reference to their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"The form asks about the patient's ability to transfer in and out of a car or van from the passenger side upon admission. This does not include the patient's ability to open or close the door or fasten their seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"The form asks about the patient's ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel, in terms of their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"The form asks about the patient's ability to go up and down a curb and/or up and down one step, as a measure of their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170N1","prefix":"GG0170N1","text":"The patient's admission performance indicates their ability to go up and down four steps, either with or without the aid of a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170O1","prefix":"GG0170O1","text":"The question on the form asks about the patient's ability to go up and down 12 steps with or without a rail. The label is \"Admission Performance\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170P1","prefix":"GG0170P1","text":"The form asks about the patient's ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor. This question is referred to as the 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130E2","prefix":"GG0130E2","text":"The form asks about the patient's ability to shower or bathe themselves, which includes washing, rinsing, and drying, but excludes washing of the back and hair. It is important to note, this does not include the patient's ability to transfer in and out of the tub or shower. The focus of this question is to understand the patient's discharge goal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130F2","prefix":"GG0130F2","text":"The patient's discharge goal includes developing the ability to dress and undress themselves above the waist, including managing fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130G2","prefix":"GG0130G2","text":"The discharge goal for the patient is to develop the ability to dress and undress below the waist, including handling fasteners, but this does not include managing footwear.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130H2","prefix":"GG0130H2","text":"The discharge goal for the patient is to develop the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including managing fasteners, if applicable.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"The patient's discharge goal is to be able to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten the seat belt.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"The patient's discharge goal is to have the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoors or outdoors.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"The discharge goal for the patient is the ability to go up and down a curb and/or up and down one step.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"The discharge goal for the patient is to develop the ability to go up and down four steps, with or without the assistance of a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"The discharge goal for the patient is to have the ability to go up and down 12 steps with or without a rail.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"The discharge goal for the patient is to develop the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Please code the patient's or resident's need for assistance with activities such as bathing, dressing, using the toilet, and eating prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"The form asks for the patient's or resident's level of need for assistance with indoor mobility, specifically walking from room to room, prior to the current illness, exacerbation, or injury. This includes whether they required a device such as a cane, crutch, or walker.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Please code the patient's or resident's need for assistance with internal or external stairs, whether with or without a device such as a cane, crutch, or walker, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Please code the patient's need for assistance with planning regular tasks, such as shopping or remembering to take medication, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"The form asks for information about the devices and aids that the patient or resident was using prior to their current illness, exacerbation, or injury. It requests that all applicable options be checked.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Please select the category that best describes the bowel continence of the patient or resident.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}]},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Please select the one category that best describes the patient's bladder continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}]},{"linkId":"Section-9/I0000","prefix":"I0000","text":"The form asks the patient to check all active diagnoses they have had in the last 7 days. It should be noted that the diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-10/J1750","prefix":"J1750","text":"Does the patient or resident have a history of falls, specifically, have they experienced two or more falls in the past year or any fall that resulted in injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}]},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Did the patient have any major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}]},{"linkId":"Section-11/K0110","prefix":"K0110","text":"Indicate the patient's usual ability to swallow by checking all applicable boxes pertaining to their swallowing and nutritional status.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}]},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Does the patient or resident have one or more unhealed pressure ulcers or injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"The form is asking the patient to report the number of Stage 2 pressure ulcers they currently have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"The patient has been asked to indicate the number of Stage 3 pressure ulcers they have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"The patient has a certain number of stage 4 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"How many unstageable pressure ulcers or injuries does the patient have due to a non-removable dressing or device?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"The form is asking the patient about the number of unstageable pressure ulcers they have due to the coverage of the wound bed by slough and/or eschar.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"The patient has a number of unstageable pressure injuries presenting as deep tissue injury.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"The form is asking the patient to disclose the number of Stage 1 pressure injuries they have.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Did a complete drug regimen review conducted for the patient identify any potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}]},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Did the facility or setting contact a physician or a designated representative by midnight of the next calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues for the patient?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-15/O0100","prefix":"O0100","text":"The patient should check all of the following special treatments, procedures, and programs that were performed on them.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}]},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"The form for the patient includes sections such as the signature, title, and date section A that need to be completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"The patient must provide their signature, title, and date in the sections where the section completion is indicated by a 'B'.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"The sections labeled \"Signature\", \"Title\", \"Sections\", and \"Date Section Completed C\" must be filled out by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"The sections of the form completed by the patient are signed and dated, with their title also mentioned.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"The patient should fill out the signature, title, and sections, then indicate the date the section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"The patient's signature, title, and the date the form sections were completed are required in section F.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"The patient needs to provide their Signature, Title, and complete the Sections mentioned in the form, including the Date Section Completed G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"The patient needs to include their signature, title, and date on the completed sections H of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"The patient needs to provide their signature and title, complete the sections, and indicate the date on which the section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"The patient is required to provide their signature, title, and the date on which the sections were completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature, their title, and fill out the sections on the form, indicating the date each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"The patient's form includes a signature, title, sections, and a section indicating the date the form was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100}],"_id":"DtgpXWwiZJh4usyoR"} {"id":"pbupcoBuWyD8N7qtY","responseType":"QuestionnaireResponse","status":"draft","authored":"2024-04-27T18:36:21.698Z","item":[{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0800","prefix":"A0800","text":"What is the patient's gender?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Female"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}]},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"What is the patient's last name?","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-36/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1100B","prefix":"A1100B","text":"What is the patient's preferred language?","type":"text","repeats":false,"readOnly":false,"maxLength":15},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"The form for the patient asks for their suffix.","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"What is the patient's National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-3/C1610E1","prefix":"C1610E1","text":"The patient's alertness level is normal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the patient or resident use a wheelchair and/or scooter upon admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"How many Stage 1 pressure injuries does the patient have?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"The patient has a certain number of stage 4 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0200","prefix":"A0200","text":"The type of provider for the patient needs to be specified.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Long-Term Care Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28448-1","display":"Long-term care hospital "}}]},{"linkId":"Section-15/O0250B","prefix":"O0250B","text":"What is the date the patient received the influenza vaccine?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A0100C","prefix":"A0100C","text":"The patient's State Medicaid Facility or Provider Number is required.","type":"text","repeats":false,"readOnly":false,"maxLength":15},{"linkId":"Section-9/I0050","prefix":"I0050","text":"Please indicate the primary medical condition category for the patient or resident.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Acute Onset Respiratory Condition (e.g., aspiration and specified bacterial pneumonias)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27513-3","display":"Acute onset respiratory condition (e.g., aspiration and specified bacterial pneumonias)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Chronic Respiratory Condition (e.g., chronic obstructive pulmonary disease)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27514-1","display":"Chronic respiratory condition (e.g., chronic obstructive pulmonary disease)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Acute Onset and Chronic Respiratory Conditions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27515-8","display":"Acute onset and chronic respiratory conditions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Chronic Cardiac Condition (e.g., heart failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27516-6","display":"Chronic cardiac condition (e.g., heart failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Other Medical Condition. If \"Other Medical Condition\", enter ICD code in the boxes."}},{"valueCoding":{"system":"http://loinc.org","code":"LA16346-1","display":"Other medical condition"}}]},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"The patient has a certain number of Stage 2 pressure ulcers.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A0210","prefix":"A0210","text":"The assessment reference date refers to the patient's observation end date.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-36/A1400","prefix":"A1400","text":"The patient needs to provide their payer information by checking all the boxes that apply.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Medicare (traditional fee-for-service)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6259-1","display":"Medicare (traditional fee-for-service)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Medicare (managed care/Part C/Medicare Advantage)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27554-7","display":"Medicare (managed care/Part C/Medicare Advantage)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Medicaid (traditional fee-for-service)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6257-5","display":"Medicaid (traditional fee-for-service)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Medicaid (managed care)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27556-2","display":"Medicaid (managed care)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Workers' compensation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6452-2","display":"Workers' compensation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Title programs (e.g., Title III, V, or XX)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6398-7","display":"Title programs (e.g., Title III, V, or XX)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Other government (e.g., TRICARE, VA, etc.)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10049-7","display":"Other government (e.g., TRICARE, VA, etc.)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Private insurance/Medigap"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10061-2","display":"Private insurance/Medigap"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Private managed care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27561-2","display":"Private managed care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Self-pay"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6369-8","display":"Self-pay"}},{"valueCoding":{"system":"http://del.cms.gov","code":"K","display":"No payer source"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18995-3","display":"No payor source"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"Other"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}]},{"linkId":"Section-15/O0100","prefix":"O0100","text":"Please check all of the following special treatments, procedures, and programs that were performed on the patient.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Non-invasive Ventilator (BIPAP, CPAP)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27542-2","display":"Non-invasive ventilator (BIPAP, CPAP)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"IV Medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27972-1","display":"IV medications, (if checked, please specify below)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H2a","display":"Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28269-1","display":"Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Dialysis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA7216-0","display":"Dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-36/A0250","prefix":"A0250","text":"What is the reason for the patient's assessment?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Admission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10922-5","display":"Admission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Planned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18067-1","display":"Planned discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://del.cms.gov","code":"12","display":"Expired"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10325-1","display":"Expired"}}]},{"linkId":"Section-36/A0050","prefix":"A0050","text":"The type of record for the patient needs to be identified.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Add new assessment/record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27573-7","display":"Add new assessment/record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Modify existing record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12664-1","display":"Modify existing record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Inactivate existing record"}},{"valueCoding":{"system":"http://loinc.org","code":"LA12665-8","display":"Inactivate existing record"}}]},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"The sections were completed and dated by the patient, who then signed and titled the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"The patient has a certain number of unstageable pressure injuries that are presenting as deep tissue injury.","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Where was the patient immediately preceding this admission? Was the patient admitted from home, another healthcare facility, or somewhere else?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11501-6","display":"Community residential setting (e.g., private home, assisted living, group home, adult foster care)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Long-term care facility (LTC)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18066-3","display":"Long-term care facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Hospital emergency department"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11504-0","display":"Hospital emergency department"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Short-stay acute hospital (IPPS)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10078-6","display":"Short-stay acute hospital (IPPS)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"Inpatient rehabilitation facility or unit (IRF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27548-9","display":"Inpatient rehabilitation facility or unit (IRF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"Psychiatric hospital or unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10065-3","display":"Psychiatric hospital or unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Intellectually Disabled/Developmentally Disabled (ID/DD) facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28224-6","display":"Intellectually disabled/developmentally disabled (ID/DD) facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Hospice"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6216-1","display":"Hospice"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-15/O0250A","prefix":"O0250A","text":"Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"The patient must provide their signature, title, and the date on which they completed Section I of the form.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"The patient needs to provide their Signature, Title, and the Date they completed Section D.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-2/B0100","prefix":"B0100","text":"The patient is in a comatose state with no discernible consciousness, persisting in a vegetative state.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Please select the one category that best describes the patient's bladder continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}]},{"linkId":"Section-3/C1610A","prefix":"C1610A","text":"Is there evidence of an acute change in the patient's or resident's mental status from their baseline?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Did a complete drug regimen review for the patient identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}]},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Does the patient understand both verbal and non-verbal content with the use of their hearing aid or device, excluding any language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}]},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Does the patient express their ideas and wants, considering both verbal and non-verbal expression and excluding language barriers?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}]},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"The discharge goal for the patient is to have the ability to get on and off a toilet or commode independently.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"The form asks about the patient's admission performance regarding their ability to transfer to and from a toilet or commode.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-36/A1200","prefix":"A1200","text":"What is the patient's marital status? Is the patient single, married, divorced, separated, or widowed?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Divorced"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}]},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"The discharge goal for the patient is to have the ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0500B","prefix":"Z0500B","text":"The date on which the Registered Nurse Assessment Coordinator signed the patient's assessment as complete.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-15/O0150B","prefix":"O0150B","text":"The patient was assessed for readiness for spontaneous breathing trial (SBT) by the second day of their Long Term Care Hospital (LTCH) stay.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Does this patient or resident have one or more unhealed pressure ulcers or injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"The signature, title, and date of the section completed F were filled out by the patient.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-36/A1100A","prefix":"A1100A","text":"Does the patient need or want an interpreter to communicate with a doctor or health care staff? Please indicate 'yes' or 'no'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Unable to determine"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11137-9","display":"Unable to determine"}}]},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"The patient completed section B and then they signed and dated the form, also providing their title.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-15/O0150A","prefix":"O0150A","text":"Was the patient on invasive mechanical ventilator support upon admission to the Long-Term Care Hospital?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No, not on invasive mechanical ventilation support upon admission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28329-3","display":"No, not on invasive mechanical ventilation support"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, weaning"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28330-1","display":"Yes, weaning"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, non-weaning"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28331-9","display":"Yes, non-weaning"}}]},{"linkId":"Section-9/I0050A","prefix":"I0050A","text":"If the patient has an \"Other Medical Condition\", they should enter the ICD code in the provided boxes.","type":"text","repeats":false,"readOnly":false,"maxLength":8},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"How many unstageable pressure ulcers does the patient have due to the coverage of the wound bed by slough and/or eschar?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"The patient's signature, title, and the date are required in the completed Section G.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"The form requires the patient's signature, title, the sections they completed, and the date on which Section E was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-11/K0200A","prefix":"K0200A","text":"Please record the most recent measurement of the patient's height in inches since their admission.","type":"integer","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-36/A0220","prefix":"A0220","text":"The admission date of the patient is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-19/Z0500A","prefix":"Z0500A","text":"The form requires the patient's signature.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Please select the one category that best describes the patient's or resident's bowel continence.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}]},{"linkId":"Section-36/A1000","prefix":"A1000","text":"The patient should check all the applicable options for their race or ethnicity.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}]},{"linkId":"Section-3/C1610B","prefix":"C1610B","text":"Did the patient's abnormal behavior fluctuate during the day, that is, did it tend to come and go or increase and decrease in severity?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"The patient needs to provide their signature and title in the designated sections and also indicate the date when each section was completed.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"The form asks if, once standing, the patient has the ability to walk at least 50 feet and make two turns for their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"How many Stage 3 pressure ulcers does the patient have?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"The form asks about the patient's admission performance regarding their ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"The form asks about the patient's admission performance in regards to their ability to move from sitting on the side of the bed to lying flat on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"The discharge goal for the patient is to gain the ability to stand up and walk at least 10 feet in a room, corridor, or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"The form asks about the patient's admission performance in terms of their ability to transfer to and from a bed to a chair or wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-3/C1610E2","prefix":"C1610E2","text":"Is the patient vigilant (hyperalert), lethargic (drowsy, easily aroused), in a stupor (difficult to arouse), or in a coma (unarousable)?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"The patient needs to provide their signature and title, and complete the relevant sections. The date when the section was completed is also required.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"The discharge goal for the patient is to achieve the ability to walk at least 150 feet in a corridor or similar space, once they are able to stand.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"The patient must provide their signature and title, as well as complete the sections indicated. The date when the section was completed has to be marked as 'A'.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}]},{"linkId":"Section-37/GG0130D1","prefix":"GG0130D1","text":"The admission performance form inquires about the patient's ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"The form asks about the patient's admission performance, specifically inquiring about their ability to stand and walk at least 150 feet in a corridor or similar space once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"The discharge goal for the patient or resident is to gain the ability to use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"The discharge goal for the patient is to once be seated in a wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"The form asks about the patient's admission performance, specifically whether, once seated in a wheelchair or scooter, they are able to wheel at least 50 feet and make two turns.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"The section labeled \"Signature, Title, Sections, Date Section Completed L\" on the patient's form needs to be filled out.","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"How many unstageable pressure ulcers or injuries does the patient have due to a non-removable dressing or device?","type":"integer","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-15/O0150C","prefix":"O0150C","text":"The patient was deemed medically ready for Spontaneous Breathing Trial (SBT) by day 2 of their Long Term Care Hospital (LTCH) stay.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"The form asks about the patient's admission performance in relation to their ability to wheel at least 150 feet in a corridor or similar space once they are seated in a wheelchair or scooter.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-9/I0000","prefix":"I0000","text":"Has the patient had any active diagnoses in the last 7 days? Please check all that apply. The diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0103","display":"Metastatic Cancer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28289-9","display":"Metastatic cancer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0104","display":"Severe Cancer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28290-7","display":"Severe cancer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0605","display":"Severe Left Systolic/Ventricular Dysfunction (known ejection fraction <= 30%)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28298-0","display":"Severe left systolic/ventricular dysfunction (known ejection fraction <= 30%)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1501","display":"Chronic Kidney Disease, Stage 5"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27518-2","display":"Chronic kidney disease, stage 5"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1502","display":"Acute Renal Failure"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27519-0","display":"Acute renal failure"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2101","display":"Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27520-8","display":"Septicemia, sepsis, systemic inflammatory response syndrome/shock"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2600","display":"Central Nervous System Infections, Opportunistic Infections, Bone/Joint/Muscle Infections/Necrosis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27521-6","display":"Central nervous system infections, opportunistic infections, bone/joint/muscle infections/necrosis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27539-8","display":"Diabetes mellitus (DM)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4100","display":"Major Lower Limb Amputation (e.g., above knee, below knee)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27522-4","display":"Major lower limb amputation (e.g., above knee, below knee)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4501","display":"Stroke"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22099-8","display":"Stroke"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4801","display":"Dementia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA20372-1","display":"Dementia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I4900","display":"Hemiplegia or Hemiparesis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27523-2","display":"Hemiplegia or hemiparesis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5000","display":"Paraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA25276-9","display":"Paraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5101","display":"Complete Tetraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27528-1","display":"Complete tetraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5102","display":"Incomplete Tetraplegia"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27529-9","display":"Incomplete tetraplegia"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5110","display":"Other Spinal Cord Disorder/Injury (e.g., myelitis, cauda equina syndrome)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27530-7","display":"Other spinal cord disorder/injury (e.g., myelitis, cauda equina syndrome)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5200","display":"Multiple Sclerosis (MS)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27531-5","display":"Multiple sclerosis (MS)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5250","display":"Huntington's Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27532-3","display":"Huntington's disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5300","display":"Parkinson's Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27533-1","display":"Parkinson's disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5450","display":"Amyotrophic Lateral Sclerosis"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27534-9","display":"Amyotrophic lateral sclerosis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5455","display":"Other Progressive Neuromuscular Disease"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28291-5","display":"Other progressive neuromuscular disease"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5460","display":"Locked-In State"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27535-6","display":"Locked-in state"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5470","display":"Severe Anoxic Brain Damage, Cerebral Edema, or Compression of Brain"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27536-4","display":"Severe anoxic brain damage, cerebral edema, or compression of brain"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5480","display":"Other Severe Neurological Injury, Disease, or Dysfunction"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28292-3","display":"Other severe neurological injury, disease, or dysfunction"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5601","display":"Malnutrition (protein or calorie)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27537-2","display":"Malnutrition (protein or calorie)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I5602","display":"At Risk for Malnutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27538-0","display":"At risk for malnutrition"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7100","display":"Lung Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28293-1","display":"Lung transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7101","display":"Heart Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28294-9","display":"Heart transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7102","display":"Liver Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28295-6","display":"Liver transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7103","display":"Kidney Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28296-4","display":"Kidney transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7104","display":"Bone Marrow Transplant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28297-2","display":"Bone marrow transplant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-36/A0700","prefix":"A0700","text":"The patient should enter a \"+\" in the Medicaid Number section if their Medicaid application is pending, or \"N\" if they are not a recipient of Medicaid.","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"The discharge goal for the patient pertains to their ability to transfer to and from a bed to a chair, which could also include a wheelchair.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"The discharge goal for the patient is the ability to transition from lying on their back to sitting on the side of the bed without any back support.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Please code the patient's or resident's need for assistance with walking from room to room, with or without a device such as a cane, crutch, or walker, prior to their current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - a helper completed the activity for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}]},{"linkId":"Section-3/C1610D","prefix":"C1610D","text":"Was the patient's or resident's thinking disorganized or incoherent, characterized by rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switches from subject to subject?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"The discharge goal for the patient is to attain the ability to stand and walk at least 50 feet, making two turns once they are standing.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"The sections of the form, including the signature and title sections, were completed by the patient on the date indicated in the \"Date Section Completed H\".","type":"text","repeats":false,"readOnly":false,"maxLength":100},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Does the patient have the ability to walk at least 10 feet in a room, corridor, or similar space once they are standing? Select from the following options for their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Did the facility or setting contact a physician, or the physician's designee, by midnight of the next calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"The discharge goal for the patient pertains to their ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, which is referred to as \"sit to stand\".","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"The discharge goal for the patient includes their ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If they are managing an ostomy, this will also include wiping the opening, but not managing the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"The form is questioning the patient's ability, once seated in a wheelchair or scooter, to wheel at least 150 feet in a corridor or similar space. This is a discharge goal.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-3/C1610C","prefix":"C1610C","text":"Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? The possible answers could be 'Yes', 'No', or 'Sometimes'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-15/O0150D","prefix":"O0150D","text":"Is there documentation of the reason or reasons in the patient's or resident's medical record that indicates why the patient or resident was deemed medically unready for SBT by the second day of their stay at the Long-Term Care Hospital?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0130D2","prefix":"GG0130D2","text":"The discharge goal for the patient is to have the ability to wash, rinse, and dry their face, hands, chest, and arms while sitting in a chair or bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-15/O0250C","prefix":"O0250C","text":"If the patient has not received the influenza vaccine, please state the reason. The options may include: a) allergic to the vaccine, b) vaccine not available, c) personal beliefs, or d) other reasons.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"{Patient/resident} not in facility during this year's influenza vaccination season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26745-2","display":"Patient not in this facility during this year's influenza vaccination season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Received outside of this facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA184-4","display":"Received outside of this facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Not eligible - medical contraindication"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11091-8","display":"Not eligible - medical contraindication"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Offered and declined"}},{"valueCoding":{"system":"http://loinc.org","code":"LA186-9","display":"Offered and declined"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Not offered"}},{"valueCoding":{"system":"http://loinc.org","code":"LA187-7","display":"Not offered"}},{"valueCoding":{"system":"http://del.cms.gov","code":"6","display":"Inability to obtain influenza vaccine due to a declared shortage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26746-0","display":"Inability to obtain influenza vaccine due to a declared shortage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"The question on the form refers to the patient or resident's eating abilities, specifically their ability to utilize appropriate utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is presented to them. This is evaluated based on their admission performance.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-15/O0150E","prefix":"O0150E","text":"If the patient or resident was deemed medically ready for a Spontaneous Breathing Trial (SBT), was the SBT performed by the second day of their Long Term Care Hospital (LTCH) stay?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}]},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"The question on the form assesses the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. The label for this section is 'Admission Performance'.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"The patient's admission performance is evaluated based on their ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If the patient is managing an ostomy, the evaluation includes their ability to wipe the opening but not manage the equipment.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"The discharge goal for the patient is to have the ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"The patient's oral hygiene refers to their ability to use suitable items to clean their teeth. If applicable, the patient's ability to handle dentures includes inserting and removing dentures from their mouth and managing denture soaking and rinsing with the use of equipment. The discharge goal needs to be determined.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-11/K0200B","prefix":"K0200B","text":"The patient's weight in pounds should be based on the most recent measure taken in the last specified number of days. The weight must be measured consistently, in accordance with the standard practice of the facility or setting, which may include measurements in the morning after voiding, before meals, with shoes off, etc.","type":"integer","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"The form inquires about the patient's admission performance concerning their ability to roll from lying on their back to their left and right side, and then return to lying on their back on the bed.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"The patient's oral hygiene pertains to their ability to use suitable items to clean their teeth. If applicable, their use of dentures involves their ability to insert and remove dentures into and from the mouth, as well as manage denture soaking and rinsing with the use of equipment. This information was gathered from their performance upon admission.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by him/herself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g. lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}]},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Please indicate the devices and aids that the patient or resident had used prior to their current illness, exacerbation, or injury. Check all that apply.","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}]}],"_id":"EK9mLigkpAXhYp9eP"} {"responseType":"QuestionnaireResponse","id":"OASIS-DAH-D1-012020","questionnaire":"OASIS-DAH-D1-012020","title":"Outcome and Assessment Information Set - Death at Home","description":"Data set for use in home health agencies (HHAs), State agencies, software vendors, professional associations and other Federal agencies in implementing and maintaining OASIS.","status":"draft","authored":"2024-04-27T18:41:02.853Z","item":[{"linkId":"Section-21/M0080","prefix":"M0080","text":"The discipline of the person who is completing the assessment for the patient is required.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"RN"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"PT"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"SLP/ST"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"OT"}}]},{"linkId":"Section-21/M0090","prefix":"M0090","text":"The date the assessment was completed for the patient.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-21/M0100_","prefix":"M0100_","text":"This assessment is currently being completed for the following reason pertaining to the patient.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA6390-4","display":"Start of care - further visits planned"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6366-4","display":"Resumption of care (after inpatient stay)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6355-7","display":"Recertification (follow-up) reassessment"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6312-8","display":"Other follow-up"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6402-7","display":"Transferred to an inpatient facility - patient not discharged from agency"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6401-9","display":"Transferred to an inpatient facility - patient discharged from agency"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6179-1","display":"Death at home"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6184-1","display":"Discharge from agency"}}]},{"linkId":"Section-20/A0100A","prefix":"A0100A","text":"Does the patient have a National Provider Identifier (NPI)?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-20/A0100B","prefix":"A0100B","text":"Does the patient have a CMS Certification Number (CCN)?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0600A","prefix":"A0600A","text":"What is the patient's Social Security Number?","type":"text","repeats":false,"readOnly":false,"maxLength":9},{"linkId":"Section-20/A0600B","prefix":"A0600B","text":"What is the patient's Medicare number?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0700","prefix":"A0700","text":"The patient's Medicaid number should be entered in the provided space. If the Medicaid application is pending, enter \"+\". If the patient is not a Medicaid recipient, enter \"N\".","type":"text","repeats":false,"readOnly":false,"maxLength":14},{"linkId":"Section-20/A0800","prefix":"A0800","text":"What is the patient's gender? The possible answers are male, female, or prefer not to say.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}]},{"linkId":"Section-20/A0900","prefix":"A0900","text":"What is the patient's birth date?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0014","prefix":"M0014","text":"In which state does the patient currently reside?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-20/M0016","prefix":"M0016","text":"What is the patient's Branch ID Number?","type":"text","repeats":false,"readOnly":false,"maxLength":10},{"linkId":"Section-20/M0020","prefix":"M0020","text":"What is the patient's or resident's ID number?","type":"text","repeats":false,"readOnly":false,"maxLength":20},{"linkId":"Section-20/M0030","prefix":"M0030","text":"What is the start of care date for the patient?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0032","prefix":"M0032","text":"The date of the patient's resumption of care is?","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-20/M0050","prefix":"M0050","text":"What is the patient's state of residence?","type":"text","repeats":false,"readOnly":false,"maxLength":2},{"linkId":"Section-20/A0550","prefix":"A0550","text":"What is the patient's or resident's ZIP code?","type":"text","repeats":false,"readOnly":false,"maxLength":11},{"linkId":"Section-20/A0500A","prefix":"A0500A","text":"What is the patient's first name?","type":"text","repeats":false,"readOnly":false,"maxLength":12},{"linkId":"Section-20/A0500B","prefix":"A0500B","text":"What is the patient's middle initial?","type":"text","repeats":false,"readOnly":false,"maxLength":1},{"linkId":"Section-20/A0500C","prefix":"A0500C","text":"The patient's last name is required.","type":"text","repeats":false,"readOnly":false,"maxLength":18},{"linkId":"Section-20/A0500D","prefix":"A0500D","text":"What is the patient's suffix?","type":"text","repeats":false,"readOnly":false,"maxLength":3},{"linkId":"Section-35/M0906","prefix":"M0906","text":"The form asks for the date of the patient's or resident's discharge, transfer, or death at home to be entered in the \"Discharge/Transfer/Death Date\" field.","type":"open-choice","repeats":false,"readOnly":false},{"linkId":"Section-31/N2005","prefix":"N2005","text":"Did the facility or setting contact and complete the actions prescribed or recommended by the physician, or the physician's designee, by midnight of the next calendar day each time potential clinically significant medication issues were identified for the patient since their admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27681-8","display":"NA-There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications"}}]},null,{"linkId":"Section-10/J1900A","prefix":"J1900A","text":"The patient exhibits no injury - there is no evidence of any injury noted on the physical assessment performed by the nurse or primary care clinician; the patient has made no complaints of pain or injury; moreover, there has been no change in the patient's behavior after the fall.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]},{"linkId":"Section-10/J1900B","prefix":"J1900B","text":"The form asks whether the patient has any minor injuries, including skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains, or any fall-related injury that has caused them to complain of pain.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]},{"linkId":"Section-10/J1900C","prefix":"J1900C","text":"Has the patient had any major injuries such as bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11073-6","display":"Two or more"}}]}],"_id":"PHwTW3993a9pyE3xB"} {"resourceType":"QuestionnaireResponse","id":"OASIS-E-012023-1","questionnaire":"OASIS-E-012023","title":"Outcome and Assessment Information Set (E)","status":"draft","authored":"2024-06-05T20:27:15.723Z","item":[{"repeats":false,"linkId":"Section A. Administrative Information /A1005","prefix":"A1005","readOnly":false,"text":"Ethnicity. Are you of Hispanic, Latino/a, or Spanish origin?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"No, not of Hispanic, Latino/a, or Spanish origin"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Yes, Mexican, Mexican American, Chicano/a"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Yes, Puerto Rican"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Yes, Cuban"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Yes, another Hispanic, Latino, or Spanish origin"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"{Patient/Resident/Person} unable to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"{Patient/Resident/Person} declines to respond"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A1010","prefix":"A1010","readOnly":false,"text":"Race. What is your race?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"White"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Asian Indian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Chinese"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Filipino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G","display":"Japanese"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Korean"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Vietnamese"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Other Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"K","display":"Native Hawaiian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"L","display":"Guamanian or Chamorro"}},{"valueCoding":{"system":"http://del.cms.gov","code":"M","display":"Samoan"}},{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"{Patient/Resident/Person} unable to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"{Patient/Resident/Person} declines to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A1110","prefix":"A1110","readOnly":false,"text":"Language","type":"question"},{"repeats":false,"linkId":"Section A. Administrative Information /A1110A","prefix":"A1110A","readOnly":false,"text":"What is your preferred language?","type":"text"},{"repeats":false,"linkId":"Section A. Administrative Information /A1110B","prefix":"A1110B","readOnly":false,"text":"Do you need or want an interpreter to communicate with a doctor or health care staff?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Unable to determine"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A1250","prefix":"A1250","readOnly":false,"text":"Transportation (from NACHC). Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed from daily living? ","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Yes, it has kept me from medical appointments or from getting my medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"X","display":"{Patient/Resident/Person} unable to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Y","display":"{Patient/Resident/Person} declines to respond"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2120","prefix":"A2120","readOnly":false,"text":"Provision of Current Reconciled Medication List to Subsequent Provider at Transfer. At the time of transfer to another provider, did your agency provide the patient's current reconciled medication list to the subsequent provider?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - Current reconciled medication list not provided to the subsequent provider"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Current reconciled medication list provided to the subsequent provider"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"NA - The agency was not made aware of this transfer timely"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2121","prefix":"A2121","readOnly":false,"text":"Provision of Current Reconciled Medication List to Subsequent Provider at Discharge. At the time of discharge to another provider, did your agency provide the patient's current reconciled medication list to the subsequent provider?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - Current reconciled medication list not provided to the subsequent provider"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Current reconciled medication list provided to the subsequent provider"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2122","prefix":"A2122","readOnly":false,"text":"Route of Current Reconciled Medication List Transmission to Subsequent Provider. ","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Electronic Health Record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Health Information Exchange"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Verbal (e.g., in-person, telephone, video conferencing)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Paper-based (e.g., fax, copies, printouts)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Other Methods (e.g., texting, email, CDs)"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2123","prefix":"A2123","readOnly":false,"text":"Provision of Current Reconciled Medication List to Patient at Discharge. At the time of discharge, did your facility provide the patient's current reconciled medication list to the patient, family and/or caregiver?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - Current reconciled medication list not provided to the {patient/resident/person}, family and/or caregiver"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Current reconciled medication list provided to the {patient/resident/person}, family and/or caregiver"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /A2124","prefix":"A2124","readOnly":false,"text":"Route of Current Reconciled Medication List Transmission to Patient. Indicate the route(s) of transmission of the current reconciled medication list to the patient/family/caregiver.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Electronic Health Record"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Health Information Exchange"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Verbal (e.g., in-person, telephone, video conferencing)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Paper-based (e.g., fax, copies, printouts)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Other Methods (e.g., texting, email, CDs)"}}]},{"repeats":false,"linkId":"Section B. Hearing, Speech, and Vision /B0200","prefix":"B0200","readOnly":false,"text":"Hearing. Ability to hear (with hearing aid or hearing appliances if normally used)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Adequate - no difficulty in normal conversation, social interaction, listening to TV"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Moderate difficulty - speaker has to increase volume and speak distinctly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Highly impaired - absence of useful hearing"}}]},{"repeats":false,"linkId":"Section B. Hearing, Speech, and Vision /B1000","prefix":"B1000","readOnly":false,"text":"Vision. Ability to see in adequate light (with glasses or other visual appliances)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Adequate - sees fine detail, such as regular print in newspapers/books"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Impaired - sees large print, but not regular print in newspapers/books"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Highly impaired - object identification in question, but eyes appear to follow objects"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects"}}]},{"repeats":false,"linkId":"Section B. Hearing, Speech, and Vision /B1300","prefix":"B1300","readOnly":false,"text":"Health Literacy. How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Often"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always"}},{"valueCoding":{"system":"http://del.cms.gov","code":"7","display":"{Patient/Resident/Person} declines to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"{Patient/Resident/Person} unable to respond"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0100","prefix":"C0100","readOnly":false,"text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all patients","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident/person} is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0200","prefix":"C0200","readOnly":false,"text":"Repetition of Three Words - Ask patient: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0300","prefix":"C0300","readOnly":false,"text":"Temporal Orientation (orientation to year, month, and day)","type":"question"},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0300A","prefix":"C0300A","readOnly":false,"text":"Ask patient: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0300B","prefix":"C0300B","readOnly":false,"text":"Ask patient: \"What month are we in right now?\" Able to report correct month","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0300C","prefix":"C0300C","readOnly":false,"text":"Ask patient: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0400","prefix":"C0400","readOnly":false,"text":"Recall. Ask patient: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"question"},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0400A","prefix":"C0400A","readOnly":false,"text":"Able to recall \"sock\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0400B","prefix":"C0400B","readOnly":false,"text":"Able to recall \"blue\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0400C","prefix":"C0400C","readOnly":false,"text":"Able to recall \"bed\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C0500","prefix":"C0500","readOnly":false,"text":"BIMS Summary Score. Add scores for C0200-C0400 and fill in total score (00-15). Enter 99 if the patient was unable to complete the interview","type":"integer"},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310","prefix":"C1310","readOnly":false,"text":"Signs and Symptoms of Delirium (from CAM©)","type":"question"},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310A","prefix":"C1310A","readOnly":false,"text":"Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the patient's baseline?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310B","prefix":"C1310B","readOnly":false,"text":"Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Behavior not present"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Behavior continuously present, does not fluctuate"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Behavior present, fluctuates (comes and goes, changes in severity)"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310C","prefix":"C1310C","readOnly":false,"text":"Disorganized Thinking - Was the patient's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Behavior not present"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Behavior continuously present, does not fluctuate"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Behavior present, fluctuates (comes and goes, changes in severity)"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /C1310D","prefix":"C1310D","readOnly":false,"text":"Altered Level of Consciousness - Did the patient have altered level of consciousness, as indicated by any of the following criteria? vigilant - startled easily to any sound or touch, lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch, stuporous - very difficult to arouse and keep aroused for the interview, comatose - could not be aroused","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Behavior not present"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Behavior continuously present, does not fluctuate"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Behavior present, fluctuates (comes and goes, changes in severity)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150","prefix":"D0150","readOnly":false,"text":"Patient Mood Interview (PHQ-2 to 9). Say to patient: \"Over the last 2 weeks, have you been bothered by any of the following problems?\"","type":"question"},{"repeats":false,"linkId":"Section D. Mood /D0150_1","prefix":"D0150_1","readOnly":false,"text":"Symptom Presence","type":"question"},{"repeats":false,"linkId":"Section D. Mood /D0150_2","prefix":"D0150_2","readOnly":false,"text":"Symptom Frequency","type":"question"},{"repeats":false,"linkId":"Section D. Mood /D0150A1","prefix":"D0150A1","readOnly":false,"text":"Little interest or pleasure in doing things - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150A2","prefix":"D0150A2","readOnly":false,"text":"Little interest of pleasure in doing things - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150B1","prefix":"D0150B1","readOnly":false,"text":"Feeling down, depressed, or hopeless - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150B2","prefix":"D0150B2","readOnly":false,"text":"Feeling down, depressed, or hopeless - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150C1","prefix":"D0150C1","readOnly":false,"text":"Trouble falling or staying asleep, or sleeping too much - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150C2","prefix":"D0150C2","readOnly":false,"text":"Trouble falling or staying asleep, or sleeping too much - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150D1","prefix":"D0150D1","readOnly":false,"text":"Feeling tired or having little energy - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150D2","prefix":"D0150D2","readOnly":false,"text":"Feeling tired or having little energy - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150E1","prefix":"D0150E1","readOnly":false,"text":"Poor appetite or overeating - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150E2","prefix":"D0150E2","readOnly":false,"text":"Poor appetite or overeating - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150F1","prefix":"D0150F1","readOnly":false,"text":"Feeling bad about yourself - or that you are a failure or have let yourself or your family down - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150F2","prefix":"D0150F2","readOnly":false,"text":"Feeling bad about yourself - or that you are a failure or have let yourself or your family down - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150G1","prefix":"D0150G1","readOnly":false,"text":"Trouble concentrating on things, such as reading the newspaper or watching television - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150G2","prefix":"D0150G2","readOnly":false,"text":"Trouble concentrating on things, such as reading the newspaper or watching television - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150H1","prefix":"D0150H1","readOnly":false,"text":"Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150H2","prefix":"D0150H2","readOnly":false,"text":"Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150I1","prefix":"D0150I1","readOnly":false,"text":"Thoughts that you would be better off dead, or of hurting yourself in some way - Symptom Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No (enter 0 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes (enter 0-3 in column 2)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"No response (leave column 2 blank)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0150I2","prefix":"D0150I2","readOnly":false,"text":"Thoughts that you would be better off dead, or of hurting yourself in some way - Symptom Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never or 1 day"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"2-6 days (several days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"7-11 days (half or more of the days)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"12-14 days (nearly every day)"}}]},{"repeats":false,"linkId":"Section D. Mood /D0160","prefix":"D0160","readOnly":false,"text":"Total Severity Score","type":"integer"},{"repeats":false,"linkId":"Section D. Mood /D0700","prefix":"D0700","readOnly":false,"text":"Social Isolation. How often do you feel lonely or isolated from those around you?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Never"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Often"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always"}},{"valueCoding":{"system":"http://del.cms.gov","code":"7","display":"{Patient/Resident/Person} declines to respond"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"{Patient/Resident/Person} unable to respond"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100","prefix":"GG0100","readOnly":false,"text":"Prior Functioning: Everyday Activities. Indicate the patient's usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100A","prefix":"GG0100A","readOnly":false,"text":"Self-Care: Code the patient's need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident/Person} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident/Person} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100B","prefix":"GG0100B","readOnly":false,"text":"Indoor Mobility (Ambulation): Code the patient's need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident/Person} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident/Person} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100C","prefix":"GG0100C","readOnly":false,"text":"Stairs: Code the patient's need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident/Person} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident/Person} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0100D","prefix":"GG0100D","readOnly":false,"text":"Functional Cognition: Code the patient's need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident/Person} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident/Person} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0110","prefix":"GG0110","readOnly":false,"text":"Prior Device Use. Indicate devices and aids used by the patient prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130","prefix":"GG0130","readOnly":false,"text":"Self-Care","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130_1","prefix":"GG0130_1","readOnly":false,"text":"Self-Care. Code the patient's usual performance at SOC/ROC for each activity using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130_2","prefix":"GG0130_2","readOnly":false,"text":"Self-Care. Code the patient's discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s).","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130_3","prefix":"GG0130_3","readOnly":false,"text":"Self-Care. Code the patient's usual performance at discharge for each activity using the 6-point scale. If any activity was not attempted at discharge, code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130_4","prefix":"GG0130_4","readOnly":false,"text":"Self-Care. Code the patient's usual performance at Follow-Up for each activity using the 6-point scale. If activity was not attempted at Follow-Up code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130A1","prefix":"GG0130A1","readOnly":false,"text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130A2","prefix":"GG0130A2","readOnly":false,"text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical condition or safety concerns"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130A3","prefix":"GG0130A3","readOnly":false,"text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130A4","prefix":"GG0130A4","readOnly":false,"text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. - Follow-up Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130B1","prefix":"GG0130B1","readOnly":false,"text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130B2","prefix":"GG0130B2","readOnly":false,"text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130B3","prefix":"GG0130B3","readOnly":false,"text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130B4","prefix":"GG0130B4","readOnly":false,"text":"Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Follow-up Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130C1","prefix":"GG0130C1","readOnly":false,"text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. 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Functional Abilities and Goals/GG0130E1","prefix":"GG0130E1","readOnly":false,"text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. 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Functional Abilities and Goals/GG0130E2","prefix":"GG0130E2","readOnly":false,"text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130E3","prefix":"GG0130E3","readOnly":false,"text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130E4","prefix":"GG0130E4","readOnly":false,"text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130F1","prefix":"GG0130F1","readOnly":false,"text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130F2","prefix":"GG0130F2","readOnly":false,"text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130F3","prefix":"GG0130F3","readOnly":false,"text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130F4","prefix":"GG0130F4","readOnly":false,"text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130G1","prefix":"GG0130G1","readOnly":false,"text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130G2","prefix":"GG0130G2","readOnly":false,"text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130G3","prefix":"GG0130G3","readOnly":false,"text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130G4","prefix":"GG0130G4","readOnly":false,"text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130H1","prefix":"GG0130H1","readOnly":false,"text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130H2","prefix":"GG0130H2","readOnly":false,"text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130H3","prefix":"GG0130H3","readOnly":false,"text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0130H4","prefix":"GG0130H4","readOnly":false,"text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170","prefix":"GG0170","readOnly":false,"text":"Mobility","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170_1","prefix":"GG0170_1","readOnly":false,"text":"Mobility. Code the patient's usual performance at SOC/ROC for each activity using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170_2","prefix":"GG0170_2","readOnly":false,"text":"Mobility. Code the patient's discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s).","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170_3","prefix":"GG0170_3","readOnly":false,"text":"Mobility. Code the patient's usual performance at discharge for each activity using the 6-point scale. If an activity was not attempted at discharge, code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170_4","prefix":"GG0170_4","readOnly":false,"text":"Mobility. Code the patient's usual performance at Follow-up for each activity using the 6-point scale. If activity was not attempted at Follow-up code the reason.","type":"question"},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170A1","prefix":"GG0170A1","readOnly":false,"text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170A2","prefix":"GG0170A2","readOnly":false,"text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170A3","prefix":"GG0170A3","readOnly":false,"text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170A4","prefix":"GG0170A4","readOnly":false,"text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Follow-up Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170B1","prefix":"GG0170B1","readOnly":false,"text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. 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Functional Abilities and Goals/GG0170R1","prefix":"GG0170R1","readOnly":false,"text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170R2","prefix":"GG0170R2","readOnly":false,"text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170R3","prefix":"GG0170R3","readOnly":false,"text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170R4","prefix":"GG0170R4","readOnly":false,"text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Follow-up Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170RR1","prefix":"GG0170RR1","readOnly":false,"text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170RR3","prefix":"GG0170RR3","readOnly":false,"text":"Indicate the type of wheelchair or scooter used. - Discharge","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170S1","prefix":"GG0170S1","readOnly":false,"text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170S2","prefix":"GG0170S2","readOnly":false,"text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170S3","prefix":"GG0170S3","readOnly":false,"text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Discharge Performance","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident/Person} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident/person} to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident/person} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident/person} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident/Person} completes the activity by {him/herself/themself} with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident/person} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"Not applicable - {Patient/Resident/Person} does not usually do this activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://del.cms.gov","code":"90","display":"Not attempted due to short-term medical conditions or safety concerns."}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170SS1","prefix":"GG0170SS1","readOnly":false,"text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}}]},{"repeats":false,"linkId":"Section GG. Functional Abilities and Goals/GG0170SS3","prefix":"GG0170SS3","readOnly":false,"text":"Indicate the type of wheelchair or scooter used. - Discharge","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J0510","prefix":"J0510","readOnly":false,"text":"Pain Effect on Sleep. Ask patient: \"Over the past 5 days, how much of the time has pain made it hard for you to sleep at night?\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Does not apply - I have not had any pain or hurting in the past 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely or not at all"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Occasionally"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Frequently"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Almost constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unable to answer"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J0520","prefix":"J0520","readOnly":false,"text":"Pain Interference with Therapy Activities. Ask patient: \"Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain?\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Does not apply - I have not received rehabilitation therapy in the past 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely or not at all"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Occasionally"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Frequently"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Almost constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unable to answer"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J0530","prefix":"J0530","readOnly":false,"text":"Pain Interference with Day-to-Day Activities. Ask patient: \"Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain?\"","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely or not at all"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Occasionally"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Frequently"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Almost constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unable to answer"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J1800","prefix":"J1800","readOnly":false,"text":"Has the patient had any falls since SOC/ROC, whichever is more recent?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J1900","prefix":"J1900","readOnly":false,"text":"Number of Falls Since SOC/ROC, whichever is most recent","type":"question"},{"repeats":false,"linkId":"Section J. Health Conditions/J1900A","prefix":"J1900A","readOnly":false,"text":"No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two or more"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J1900B","prefix":"J1900B","readOnly":false,"text":"Injury (except major): skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two or more"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/J1900C","prefix":"J1900C","readOnly":false,"text":"Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two or more"}}]},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/K0520","prefix":"K0520","readOnly":false,"text":"Nutritional Approaches","type":"question"},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/K0520_1","prefix":"K0520_1","readOnly":false,"text":"Check all of the following nutritional approaches that apply on {admission}","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Parenteral/IV feeding"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Feeding tube (e.g., nasogastric or abdominal (PEG))"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Therapeutic diet (e.g., low salt, diabetic, low cholesterol)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/K0520_4","prefix":"K0520_4","readOnly":false,"text":"Check all of the nutritional approaches that were received in the last 7 days","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Parenteral/IV feeding"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Feeding tube (e.g., nasogastric or abdominal (PEG))"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Therapeutic diet (e.g., low salt, diabetic, low cholesterol)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section K. 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Active Diagnoses/M1023_E2_ICD","prefix":"M1023_E2_ICD","readOnly":false,"text":"Other Diagnosis e.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (no diagnosis code)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"ICD","display":"ICD-10 diagnosis code"}}]},{"repeats":false,"linkId":"Section I. Active Diagnoses/M1023_E2_SEV","prefix":"M1023_E2_SEV","readOnly":false,"text":"Symptom Control Rating e.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"No severity rating"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Asymptomatic, no treatment needed at this time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Symptoms well controlled with current therapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Symptoms controlled with difficulty, affecting daily functioning; {patient/resident/person} needs ongoing monitoring"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Symptoms poorly controlled: {patient/resident/person} needs frequent adjustment in treatment and dose monitoring"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Symptoms poorly controlled: history of re-hospitalizations"}}]},{"repeats":false,"linkId":"Section I. Active Diagnoses/M1023_F2_ICD","prefix":"M1023_F2_ICD","readOnly":false,"text":"Other Diagnosis f.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (no diagnosis code)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"ICD","display":"ICD-10 diagnosis code"}}]},{"repeats":false,"linkId":"Section I. Active Diagnoses/M1023_F2_SEV","prefix":"M1023_F2_SEV","readOnly":false,"text":"Symptom Control Rating f.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"No severity rating"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Asymptomatic, no treatment needed at this time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Symptoms well controlled with current therapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Symptoms controlled with difficulty, affecting daily functioning; {patient/resident/person} needs ongoing monitoring"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Symptoms poorly controlled: {patient/resident/person} needs frequent adjustment in treatment and dose monitoring"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Symptoms poorly controlled: history of re-hospitalizations"}}]},{"repeats":false,"linkId":"Section I. Active Diagnoses/M1028","prefix":"M1028","readOnly":false,"text":"Active Diagnoses - Comorbidities and Co-existing Conditions: Check all that apply. See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Diabetes Mellitus (DM)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"None of the above"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/M1033","prefix":"M1033","readOnly":false,"text":"Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? Check all that apply","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"History of falls (2 or more falls - or any fall with an injury - in the past 12 months)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unintentional weight loss of a total of 10 pounds or more in the past 12 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Multiple hospitalizations (2 or more) in the past 6 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Multiple emergency department visits (2 or more) in the past 6 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Decline in mental, emotional, or behavioral status in the past 3 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months"}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"Currently taking 5 or more medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"Currently reports exhaustion"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Other risk(s) not listed in 1 - 8"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"None of the above"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/M1041","prefix":"M1041","readOnly":false,"text":"Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/M1046","prefix":"M1046","readOnly":false,"text":"Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year's flu season?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Yes; received from another health care provider (for example, physician, pharmacist)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"No; {patient/resident/person} offered and declined"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"No; {patient/resident/person} assessed and determined to have medical contraindication(s)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"No; not indicated - {patient/resident/person} does not meet age/condition guidelines for influenza vaccine"}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"No; inability to obtain vaccine due to declared shortage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"No; {patient/resident/person} did not receive the vaccine due to reasons other than those listed in responses 4 - 7"}}]},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/M1060","prefix":"M1060","readOnly":false,"text":"Height and Weight. While measuring, if the number is X.1-X.4 round down, X.5 or greater round up","type":"question"},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/M1060_A","prefix":"M1060_A","readOnly":false,"text":"Height (in inches). Record most recent height measure since the most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/M1060_B","prefix":"M1060_B","readOnly":false,"text":"Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to standard agency practice (for example, in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer"},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M1100","prefix":"M1100","readOnly":false,"text":"Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only.)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident/Person} lives alone, around the clock assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident/Person} lives alone, regular daytime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} lives alone, regular nighttime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"{Patient/Resident/Person} lives alone, occasional / short-term assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"{Patient/Resident/Person} lives alone, no assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"{Patient/Resident/Person} lives with other person(s) in the home, around the clock assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident/Person} lives with other person(s) in the home, regular daytime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"08","display":"{Patient/Resident/Person} lives with other person(s) in the home, regular nighttime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"{Patient/Resident/Person} lives with other person(s) in the home, occasional/short-term assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"{Patient/Resident/Person} lives with other person(s) in the home, no assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"11","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), around the clock assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"12","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), regular daytime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"13","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), regular nighttime assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"14","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), occasional / short-term assistance available."}},{"valueCoding":{"system":"http://del.cms.gov","code":"15","display":"{Patient/Resident/Person} lives in congregate situation (for example, assisted living, residential care home), no assistance available."}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1306","prefix":"M1306","readOnly":false,"text":"Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? (Excludes Stage 1 pressure injuries and all healed pressure ulcers/injuries)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1307","prefix":"M1307","readOnly":false,"text":"The Oldest Stage 2 Pressure Ulcer that is present at discharge: (Excludes healed Stage 2 Pressure Ulcers)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Was present at the most recent SOC/ROC assessment"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Developed since the most recent SOC/ROC assessment"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"No Stage 2 pressure ulcers are present at discharge"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1307_DT","prefix":"M1307_DT","readOnly":false,"text":"Record date pressure ulcer first identified","type":"date"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311","prefix":"M1311","readOnly":false,"text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Admission","type":"question"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_A1","prefix":"M1311_A1","readOnly":false,"text":"Number of Stage 2 pressure ulcers","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_A2","prefix":"M1311_A2","readOnly":false,"text":"Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_B1","prefix":"M1311_B1","readOnly":false,"text":"Number of Stage 3 pressure ulcers","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_B2","prefix":"M1311_B2","readOnly":false,"text":"Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_C1","prefix":"M1311_C1","readOnly":false,"text":"Number of Stage 4 pressure ulcers","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_C2","prefix":"M1311_C2","readOnly":false,"text":"Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_D1","prefix":"M1311_D1","readOnly":false,"text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_D2","prefix":"M1311_D2","readOnly":false,"text":"Number of these unstageable pressure ulcers/injuries that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_E1","prefix":"M1311_E1","readOnly":false,"text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_E2","prefix":"M1311_E2","readOnly":false,"text":"Number of these unstageable pressure ulcers that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_F1","prefix":"M1311_F1","readOnly":false,"text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1311_F2","prefix":"M1311_F2","readOnly":false,"text":"Number of these unstageable pressure injuries that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC","type":"integer"},{"repeats":false,"linkId":"Section M. Skin Conditions/M1322","prefix":"M1322","readOnly":false,"text":"Current Number of Stage 1 Pressure Injuries. Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"0"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"1"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"2"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"3"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"4 or more"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1324","prefix":"M1324","readOnly":false,"text":"Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable. Excludes pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar, or deep tissue injury.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Stage 1"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Stage 2"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Stage 3"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Stage 4"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} has no pressure ulcers/injuries or no stageable pressure ulcers/injuries"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1330","prefix":"M1330","readOnly":false,"text":"Does this patient have a Stasis Ulcer?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes, {patient/resident/person} has BOTH observable and unobservable stasis ulcers."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Yes, {patient/resident/person} has observable stasis ulcers ONLY."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Yes, {patient/resident/person} has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing/device)"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1332","prefix":"M1332","readOnly":false,"text":"Current Number of Stasis Ulcer(s) that are Observable","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Four or more"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1334","prefix":"M1334","readOnly":false,"text":"Status of Most Problematic Stasis Ulcer that is Observable","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Fully granulating"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Early/partial granulation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Not healing"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1340","prefix":"M1340","readOnly":false,"text":"Does this patient have a Surgical Wound?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes, {patient/resident/person} has at least one observable surgical wound"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Surgical wound known but not observable due to non-removable dressing/device"}}]},{"repeats":false,"linkId":"Section M. Skin Conditions/M1342","prefix":"M1342","readOnly":false,"text":"Status of Most Problematic Surgical Wound that is Observable","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Newly epithelialized"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Fully granulating"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Early/partial granulation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Not healing"}}]},{"repeats":false,"linkId":"Section J. Health Conditions/M1400","prefix":"M1400","readOnly":false,"text":"When is the patient dyspneic or noticeably Short of Breath?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"{Patient/Resident/Person} is not short of breath"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"When walking more than 20 feet, climbing stairs"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"With moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than 20 feet)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"With minimal exertion (for example, while eating, talking, or performing other ADLs) or with agitation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"At rest (during day or night)"}}]},{"repeats":false,"linkId":"Section H. Bladder and Bowel/M1600","prefix":"M1600","readOnly":false,"text":"Has this patient been treated for a Urinary Tract Infection in the past 14 days?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} on prophylactic treatment"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Unknown"}}]},{"repeats":false,"linkId":"Section H. Bladder and Bowel/M1610","prefix":"M1610","readOnly":false,"text":"Urinary Incontinence or Urinary Catheter Presence","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No incontinence or catheter (includes anuria or ostomy for urinary drainage)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident/Person} is incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident/Person} requires a urinary catheter (specifically: external, indwelling, intermittent, or suprapubic)"}}]},{"repeats":false,"linkId":"Section H. Bladder and Bowel/M1620","prefix":"M1620","readOnly":false,"text":"Bowel Incontinence Frequency","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Very rarely or never has bowel incontinence"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Less than once weekly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"One to three times weekly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Four to six times weekly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"On a daily basis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"More often than once daily"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} has ostomy for bowel elimination"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Unknown"}}]},{"repeats":false,"linkId":"Section H. Bladder and Bowel/M1630","prefix":"M1630","readOnly":false,"text":"Ostomy for Bowel Elimination. Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay; or b) necessitated a change in medical or treatment regimen?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"{Patient/Resident/Person} does not have an ostomy for bowel elimination."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient's/Resident's} ostomy was not related to an inpatient stay and did not necessitate change in medical or treatment regimen."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"The ostomy was related to an inpatient stay or did necessitate change in medical or treatment regimen."}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /M1700","prefix":"M1700","readOnly":false,"text":"Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Requires assistance and some direction in specific situations (for example, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Requires considerable assistance in routine situations. Is not alert and oriented or is unable to shift attention and recall directions more than half the time."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium."}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /M1710","prefix":"M1710","readOnly":false,"text":"When Confused. Reported or Observed Within the Last 14 Days.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Never"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"In new or complex situations only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"On awakening or at night only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"During the day and evening, but not constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} nonresponsive"}}]},{"repeats":false,"linkId":"Section C. Cognitive Patterns /M1720","prefix":"M1720","readOnly":false,"text":"When Anxious. Reported or Observed Within the Last 14 Days.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"None of the time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Less often than daily"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Daily, but not constantly"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"All of the time"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} nonresponsive"}}]},{"repeats":false,"linkId":"Section E. Behavior /M1740","prefix":"M1740","readOnly":false,"text":"Cognitive, Behavioral, and Psychiatric symptoms that are demonstrated at least once a week (Reported or Observed). Check all that apply","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Memory deficit: failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Verbal disruption: yelling, threatening, excessive profanity, sexual references, etc."}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Physical aggression: aggressive or combative to self and others (for example, hits self, throws objects, punches, dangerous maneuvers with wheelchair or other objects)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"Disruptive, infantile, or socially inappropriate behavior (excludes verbal actions)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"6","display":"Delusional, hallucinatory, or paranoid behavior"}},{"valueCoding":{"system":"http://del.cms.gov","code":"7","display":"None of the above behaviors demonstrated"}}]},{"repeats":false,"linkId":"Section E. Behavior /M1745","prefix":"M1745","readOnly":false,"text":"Frequency of Disruptive Behavior Symptoms (Reported or Observed). Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Never"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Less than once a month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Once a month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Several times each month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Several times a week"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"At least daily"}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1800","prefix":"M1800","readOnly":false,"text":"Grooming. Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care).","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to groom self unaided, with or without the use of assistive devices or adapted methods."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Grooming utensils must be placed within reach before able to complete grooming activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Someone must assist the {patient/resident/person} to groom self."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} depends entirely upon someone else for grooming needs."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1810","prefix":"M1810","readOnly":false,"text":"Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons and snaps.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to dress upper body without assistance if clothing is laid out or handed to the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Someone must help the {patient/resident/person} put on upper body clothing."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} depends entirely upon another person to dress the upper body."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1820","prefix":"M1820","readOnly":false,"text":"Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to obtain, put on, and remove clothing and shoes without assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to dress lower body without assistance if clothing and shoes are laid out or handed to the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Someone must help the {patient/resident/person} put on undergarments, slacks, socks or nylons, and shoes."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} depends entirely upon another person to dress lower body."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1830","prefix":"M1830","readOnly":false,"text":"Bathing. Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to bathe self in shower or tub independently, including getting in and out of tub/shower."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of the tub/shower."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Unable to participate effectively in bathing and is bathed totally by another person."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1840","prefix":"M1840","readOnly":false,"text":"Toilet Transferring. Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to get to and from the toilet and transfer independently with or without a device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Is totally dependent in toileting."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1845","prefix":"M1845","readOnly":false,"text":"Toileting Hygiene. Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to manage toileting hygiene and clothing management without assistance."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the {patient/resident/person}."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Someone must help the {patient/resident/person} to maintain toileting hygiene and/or adjust clothing."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} depends entirely upon another person to maintain toileting hygiene."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1850","prefix":"M1850","readOnly":false,"text":"Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently transfer."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to transfer with minimal human assistance or with use of an assistive device."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Able to bear weight and pivot during the transfer process but unable to transfer self."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Unable to transfer self and is unable to bear weight or pivot when transferred by another person."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Bedfast, unable to transfer but is able to turn and position self in bed."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Bedfast, unable to transfer and is unable to turn and position self."}}]},{"repeats":false,"linkId":"Section G. Functional Status/M1860","prefix":"M1860","readOnly":false,"text":"Ambulation/Locomotion. Current ability to walk safely, once in a standing position, or use a wheelchair, once in in a seated position, on a variety of surfaces.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (specifically: needs no human assistance or assistive device)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Requires use of a two-handed device (for example, walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Able to walk only with the supervision or assistance of another person at all times."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Chairfast, unable to ambulate but is able to wheel self independently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Chairfast, unable to ambulate and is unable to wheel self."}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Bedfast, unable to ambulate or be up in a chair."}}]},{"repeats":false,"linkId":"Section K. Swallowing/Nutritional Status/M1870","prefix":"M1870","readOnly":false,"text":"Feeding or Eating. Current ability to feed self meals and snacks safely. Note: This refers only to the process of eating, chewing, and swallowing, not preparing the food to be eaten.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently feed self."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to feed self independently but requires: (a) meal set-up; OR (b) intermittent assistance or supervision from another person; OR (c) a liquid, pureed or ground meat diet."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Unable to feed self and must be assisted or supervised throughout the meal/snack."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Able to take in nutrients orally and receives supplemental nutrients though a nasogastric tube or gastrostomy."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Unable to take in nutrients orally or by tube feeding."}}]},{"repeats":false,"linkId":"Section N. Medications /M2001","prefix":"M2001","readOnly":false,"text":"Drug Regimen Review. Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident/Person} is not taking any medications"}}]},{"repeats":false,"linkId":"Section N. Medications /M2003","prefix":"M2003","readOnly":false,"text":"Medication Follow-up. Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}}]},{"repeats":false,"linkId":"Section N. Medications /M2005","prefix":"M2005","readOnly":false,"text":"Medication Intervention. Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - There were no potential clinically significant medication issues identified since {admission} or {patient/resident/person} is not taking any medications"}}]},{"repeats":false,"linkId":"Section N. Medications /M2010","prefix":"M2010","readOnly":false,"text":"Patient/Caregiver High-Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} not taking any high-risk drugs OR {patient/resident/person}/caregiver fully knowledgeable about special precautions associated with all high-risk medications"}}]},{"repeats":false,"linkId":"Section N. Medications /M2016","prefix":"M2016","readOnly":false,"text":"Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"{Patient/Resident/Person} not taking any drugs"}}]},{"repeats":false,"linkId":"Section N. Medications /M2020","prefix":"M2020","readOnly":false,"text":"Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. Excludes injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness.)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Able to take medication(s) at the correct times if given reminders by another person at the appropriate times"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Unable to take medication unless administered by another person."}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"No oral medications prescribed."}}]},{"repeats":false,"linkId":"Section N. Medications /M2030","prefix":"M2030","readOnly":false,"text":"Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. Excludes IV medications.","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"Able to independently take the correct medication(s) and proper dosage(s) at the correct times."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Unable to take injectable medication unless administered by another person."}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"No injectable medications prescribed."}}]},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102","prefix":"M2102","readOnly":false,"text":"Types and Sources of Assistance. Determine the ability and willingness of non-agency caregivers (such as family members, friends, or privately paid caregivers) to provide assistance for the following activities, if assistance is needed. Excludes all care by your agency staff.","type":"question"},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102_A","prefix":"M2102_A","readOnly":false,"text":"ADL assistance (for example, transfer/ambulation, bathing, dressing, toileting, eating/feeding)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No assistance needed - {patient/resident/person} is independent or does not have needs in this area"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Non-agency caregiver(s) currently provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Non-agency caregiver(s) need training/supportive services to provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Assistance needed, but no non-agency caregiver(s) available"}}]},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102_C","prefix":"M2102_C","readOnly":false,"text":"Medication administration (for example, oral, inhaled or injectable)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No assistance needed - {patient/resident/person} is independent or does not have needs in this area"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Non-agency caregiver(s) currently provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Non-agency caregiver(s) need training/supportive services to provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Assistance needed, but no non-agency caregiver(s) available"}}]},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102_D","prefix":"M2102_D","readOnly":false,"text":"Medical procedures/treatments (for example, changing wound dressing, home exercise program)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No assistance needed - {patient/resident/person} is independent or does not have needs in this area"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Non-agency caregiver(s) currently provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Non-agency caregiver(s) need training/supportive services to provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Assistance needed, but no non-agency caregiver(s) available"}}]},{"repeats":false,"linkId":"Section F. Preferences for Customary Routine and Activities/M2102_F","prefix":"M2102_F","readOnly":false,"text":"Supervision and safety (for example, due to cognitive impairment)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No assistance needed - {patient/resident/person} is independent or does not have needs in this area"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Non-agency caregiver(s) currently provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Non-agency caregiver(s) need training/supportive services to provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Assistance needed, but no non-agency caregiver(s) available"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/M2200","prefix":"M2200","readOnly":false,"text":"Therapy Need. In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits (total of reasonable and necessary physical, occupational, and speech-language pathology visits combined)? Enter zero [\"000\"] if no therapy visits indicated.","type":"integer"},{"repeats":false,"linkId":"Section A. Administrative Information /M2301","prefix":"M2301","readOnly":false,"text":"Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes, used hospital emergency department WITHOUT hospital admission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Yes, used hospital emergency department WITH hospital admission"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Unknown"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /M2310","prefix":"M2310","readOnly":false,"text":"Reason for Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or without hospitalization)? (Check all that apply)","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Improper medication administration, adverse drug reactions, medication side effects, toxicity, anaphylaxis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Hypo/Hyperglycemia, diabetes out of control"}},{"valueCoding":{"system":"http://del.cms.gov","code":"19","display":"Other than above reasons"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Reason unknown"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401","prefix":"M2401","readOnly":false,"text":"Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? (Check only one box in each row)","type":"question"},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_B","prefix":"M2401_B","readOnly":false,"text":"Falls prevention interventions","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_C","prefix":"M2401_C","readOnly":false,"text":"Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_D","prefix":"M2401_D","readOnly":false,"text":"Intervention(s) to monitor and mitigate pain","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_E","prefix":"M2401_E","readOnly":false,"text":"Intervention(s) to prevent pressure ulcers","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section Q. Participation in Assessment and Goal Setting/M2401_F","prefix":"M2401_F","readOnly":false,"text":"Pressure ulcer treatment based on principles of moist wound healing","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"00","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"Not applicable"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /M2410","prefix":"M2410","readOnly":false,"text":"To which Inpatient Facility has the patient been admitted?","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Rehabilitation facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Nursing home"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Hospice"}},{"valueCoding":{"system":"http://del.cms.gov","code":"NA","display":"No inpatient facility admission"}}]},{"repeats":false,"linkId":"Section A. Administrative Information /M2420","prefix":"M2420","readOnly":false,"text":"Discharge Disposition: Where is the patient after discharge from your agency? Choose only one answer","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"{Patient/Resident/Person} remained in the community (without formal assistive services)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"{Patient/Resident/Person} remained in the community (with formal assistive services)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"{Patient/Resident/Person} transferred to a non-institutional hospice"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Unknown because {patient/resident/person} moved to a geographic location not served by this agency"}},{"valueCoding":{"system":"http://del.cms.gov","code":"UK","display":"Other unknown"}}]},{"repeats":false,"linkId":"Section N. Medications /N0415","prefix":"N0415","readOnly":false,"text":"High-Risk Drug Classes: Use and Indication","type":"question"},{"repeats":false,"linkId":"Section N. Medications /N0415_1","prefix":"N0415_1","readOnly":false,"text":"Check if the patient is taking any medications by pharmacological classification, not how it is used, in the following classes","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Antipsychotic"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Anticoagulant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Antibiotic"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Opioid"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Antiplatelet"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Hypoglycemic (including insulin)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section N. Medications /N0415_2","prefix":"N0415_2","readOnly":false,"text":"High-Risk Drug Classes: Use and Indication - Indication noted","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"^","display":"Blank (skip pattern)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Antipsychotic"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Anticoagulant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"Antibiotic"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H","display":"Opioid"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I","display":"Antiplatelet"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J","display":"Hypoglycemic (including insulin)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/O0110","prefix":"O0110","readOnly":false,"text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that apply.","type":"question"},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/O0110_a","prefix":"O0110_a","readOnly":false,"text":"Special Treatments, Procedures, and Programs - On Admission","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A1","display":"Chemotherapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A10","display":"Chemotherapy - Other"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A2","display":"Chemotherapy - IV"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A3","display":"Chemotherapy - Oral"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B1","display":"Radiation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C1","display":"Oxygen Therapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C2","display":"Oxygen Therapy - Continuous"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C3","display":"Oxygen Therapy - Intermittent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C4","display":"Oxygen Therapy - High-concentration"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D1","display":"Suctioning"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D2","display":"Suctioning - Scheduled"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D3","display":"Suctioning - As Needed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E1","display":"Tracheostomy care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F1","display":"Invasive Mechanical Ventilator (ventilator or respirator)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G1","display":"Non-Invasive Mechanical Ventilator"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G2","display":"Non-Invasive Mechanical Ventilator - BiPAP"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G3","display":"Non-Invasive Mechanical Ventilator - CPAP"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H1","display":"IV Medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H10","display":"IV Medications - Other"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H2","display":"IV Medications - Vasoactive medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H3","display":"IV Medications - Antibiotics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H4","display":"IV Medications - Anticoagulant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1","display":"Transfusions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J1","display":"Dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J2","display":"Dialysis - Hemodialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J3","display":"Dialysis - Peritoneal dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O1","display":"IV Access"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O2","display":"IV Access - Peripheral"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O3","display":"IV Access - Midline"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O4","display":"IV Access - Central (e.g., PICC, tunneled, port)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z1","display":"None of the Above"}}]},{"repeats":false,"linkId":"Section O. Special Treatments, Procedures, and Programs/O0110_c","prefix":"O0110_c","readOnly":false,"text":"Special Treatments, Procedures, and Programs - At Discharge","type":"choice","answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"-","display":"Not assessed/no information"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A1","display":"Chemotherapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A10","display":"Chemotherapy - Other"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A2","display":"Chemotherapy - IV"}},{"valueCoding":{"system":"http://del.cms.gov","code":"A3","display":"Chemotherapy - Oral"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B1","display":"Radiation"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C1","display":"Oxygen Therapy"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C2","display":"Oxygen Therapy - Continuous"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C3","display":"Oxygen Therapy - Intermittent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C4","display":"Oxygen Therapy - High-concentration"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D1","display":"Suctioning"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D2","display":"Suctioning - Scheduled"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D3","display":"Suctioning - As Needed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E1","display":"Tracheostomy care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F1","display":"Invasive Mechanical Ventilator (ventilator or respirator)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G1","display":"Non-Invasive Mechanical Ventilator"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G2","display":"Non-Invasive Mechanical Ventilator - BiPAP"}},{"valueCoding":{"system":"http://del.cms.gov","code":"G3","display":"Non-Invasive Mechanical Ventilator - CPAP"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H1","display":"IV Medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H10","display":"IV Medications - Other"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H2","display":"IV Medications - Vasoactive medications"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H3","display":"IV Medications - Antibiotics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"H4","display":"IV Medications - Anticoagulant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I1","display":"Transfusions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J1","display":"Dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J2","display":"Dialysis - Hemodialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"J3","display":"Dialysis - Peritoneal dialysis"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O1","display":"IV Access"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O2","display":"IV Access - Peripheral"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O3","display":"IV Access - Midline"}},{"valueCoding":{"system":"http://del.cms.gov","code":"O4","display":"IV Access - Central (e.g., PICC, tunneled, port)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z1","display":"None of the Above"}}]}],"_id":"vfRmZydPh5dkkJHL5"} {"responseType":"QuestionnaireResponse","questionnaire":"HIS-HA-2.00.0","id":"HIS-HA-2.00.0-1","title":"Hospice Item Set - Hospice Admission Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-09-20T06:29:57.933Z","item":[{"linkId":"Section-36","text":"Section A: Administrative Information","type":"group","readOnly":true,"item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0"},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3"},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5"},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Admitted From. Immediately preceding this admission, where was the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.6"},{"linkId":"Section-36/A0550","prefix":"A0550","text":"{Patient/Resident} ZIP Code.","type":"text","repeats":false,"readOnly":false,"maxLength":11,"id":"item.0.item.7"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1"}],"id":"item.0.item.8"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3"}],"id":"item.0.item.9"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1"}],"id":"item.0.item.10"},{"linkId":"Section-36/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.11"},{"linkId":"Section-36/A1400","prefix":"A1400","text":"Payer Information: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.12"},{"linkId":"Section-36/A0205","prefix":"A0205","text":"Site of Service at Admission","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.13"},{"linkId":"Section-36/A0245","prefix":"A0245","text":"Date Initial Nursing Assessment Initiated","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.14"}],"id":"item.0","description":"The patient must fill out Section A, which pertains to administrative information."},{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0","description":"The form asks the patient to enter their Medicaid number. If their Medicaid is still pending, they should enter \"+\". If they are not a Medicaid recipient, they should enter \"N\"."},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1","description":"What is the patient's gender? The options are male, female, or prefer not to say."},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2","description":"What is the patient's date of birth?"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3","description":"The type of record for the patient needs to be identified."},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4","description":"What is the reason for the patient's assessment?"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5","description":"What is the patient's admission date?"},{"linkId":"Section-36/A1802","prefix":"A1802","text":"Admitted From. Immediately preceding this admission, where was the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.6","description":"Where was the patient immediately preceding this admission? Was the patient admitted from their home, another hospital, a nursing home, or somewhere else?"},{"linkId":"Section-36/A0550","prefix":"A0550","text":"{Patient/Resident} ZIP Code.","type":"text","repeats":false,"readOnly":false,"maxLength":11,"id":"item.0.item.7","description":"What is the patient's or resident's ZIP code?"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1"}],"id":"item.0.item.8","description":"The patient needs to provide the numbers associated with their facility provider."},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.8.item.0","description":"What is the patient's National Provider Identifier (NPI)?"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.1","description":"What is the patient's CMS Certification Number (CCN)?"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.9.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.9.item.3"}],"id":"item.0.item.9","description":"What is the legal name of the patient or resident?"},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.0","description":"What is the patient's first name?"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.9.item.1","description":"What is the patient's middle initial?"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last 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numbers."},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.10.item.0","description":"What is the patient's Social Security Number?"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.10.item.1","description":"What is the patient's Medicare number?"},{"linkId":"Section-36/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.11","description":"The patient must check all the boxes that apply to their race or ethnicity."},{"linkId":"Section-36/A1400","prefix":"A1400","text":"Payer Information: Check all that apply","type":"text","repeats":true,"readOnly":false,"maxLength":1,"id":"item.0.item.12","description":"The patient should provide all applicable payer information by checking all the relevant options."},{"linkId":"Section-36/A0205","prefix":"A0205","text":"Site of Service at Admission","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.13","description":"What was the patient's site of service at the time of admission?"},{"linkId":"Section-36/A0245","prefix":"A0245","text":"Date Initial Nursing Assessment Initiated","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.14","description":"The date the initial nursing assessment for the patient was initiated."},{"linkId":"Section-47","text":"Section F: Preferences","type":"group","readOnly":true,"item":[{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0"},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1"}],"id":"item.1.item.0"},{"linkId":"Section-47/F2100","prefix":"F2100","text":"Other Life-Sustaining Treatment Preferences","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0"},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1"}],"id":"item.1.item.1"},{"linkId":"Section-47/F2200","prefix":"F2200","text":"Hospitalization Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0"},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1"}],"id":"item.1.item.2"},{"linkId":"Section-47/F3000","prefix":"F3000","text":"Spiritual/Existential Concerns","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0"},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1"}],"id":"item.1.item.3"}],"id":"item.1","description":"In section F of the form, the patient's preferences are discussed."},{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0"},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1"}],"id":"item.1.item.0","description":"Does the patient have a preference regarding CPR?"},{"linkId":"Section-47/F2000A","prefix":"F2000A","text":"Was the {patient/resident}/responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR)? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.0.item.0","description":"Was the patient, or the responsible party, asked about their preference regarding the use of cardiopulmonary resuscitation (CPR)? Please select the most accurate response."},{"linkId":"Section-47/F2000B","prefix":"F2000B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding the use of CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.0.item.1","description":"The date when the patient or responsible party was first asked about their preference regarding the use of CPR."},{"linkId":"Section-47/F2100","prefix":"F2100","text":"Other Life-Sustaining Treatment Preferences","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0"},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1"}],"id":"item.1.item.1","description":"Does the patient have other life-sustaining treatment preferences?"},{"linkId":"Section-47/F2100A","prefix":"F2100A","text":"Was the {patient/resident}/responsible party asked about preferences regarding life-sustaining treatments other than CPR? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.1.item.0","description":"Was the patient or responsible party asked about their preferences regarding life-sustaining treatments other than CPR? Please select the most accurate response."},{"linkId":"Section-47/F2100B","prefix":"F2100B","text":"Date the {patient/resident}/responsible party was first asked about preferences regarding life-sustaining treatments other than CPR:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.1.item.1","description":"The date on which the patient or responsible party was first asked about their preferences regarding life-sustaining treatments other than Cardiopulmonary Resuscitation was:"},{"linkId":"Section-47/F2200","prefix":"F2200","text":"Hospitalization Preference","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0"},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1"}],"id":"item.1.item.2","description":"The patient has to choose their hospitalization preference."},{"linkId":"Section-47/F2200A","prefix":"F2200A","text":"Was the {patient/resident}/responsible party asked about preference regarding hospitalization? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.2.item.0","description":"Was the patient or the responsible party asked about their preference regarding hospitalization? Please select the most accurate response."},{"linkId":"Section-47/F2200B","prefix":"F2200B","text":"Date the {patient/resident}/responsible party was first asked about preference regarding hospitalization:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.2.item.1","description":"The date that the patient, resident, or responsible party was first asked about their preference regarding hospitalization was:"},{"linkId":"Section-47/F3000","prefix":"F3000","text":"Spiritual/Existential Concerns","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0"},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1"}],"id":"item.1.item.3","description":"Does the patient have any spiritual or existential concerns?"},{"linkId":"Section-47/F3000A","prefix":"F3000A","text":"Was the {patient/resident} and/or caregiver asked about spiritual/existential concerns? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.1.item.3.item.0","description":"Was the patient or resident and/or their caregiver asked about any spiritual or existential concerns? Please select the most accurate response."},{"linkId":"Section-47/F3000B","prefix":"F3000B","text":"Date the {patient/resident} and/or caregiver was first asked about spiritual/existential concerns:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.3.item.1","description":"When was the patient or their caregiver first asked about their spiritual or existential concerns?"},{"linkId":"Section-9","text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal Diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"}],"id":"item.2","description":"In Section I of the form, the patient's active diagnoses are listed."},{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal Diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"What is the patient's principal diagnosis?"},{"linkId":"Section-10","text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J0900","prefix":"J0900","text":"Pain Screening","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3"}],"id":"item.3.item.0"},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Pain Active Problem. Is pain an active problem for the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.1"},{"linkId":"Section-10/J0910","prefix":"J0910","text":"Comprehensive Pain Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2"}],"id":"item.3.item.2"},{"linkId":"Section-10/J2030","prefix":"J2030","text":"Screening for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2"}],"id":"item.3.item.3"},{"linkId":"Section-10/J2040","prefix":"J2040","text":"Treatment for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0"},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2"}],"id":"item.3.item.4"}],"id":"item.3","description":"In Section J of the form, the patient is asked about their health conditions."},{"linkId":"Section-10/J0900","prefix":"J0900","text":"Pain Screening","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3"}],"id":"item.3.item.0","description":"The patient is asked to participate in a pain screening."},{"linkId":"Section-10/J0900A","prefix":"J0900A","text":"Was the {patient/resident} screened for pain?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.0","description":"Was the patient or resident screened for pain?"},{"linkId":"Section-10/J0900B","prefix":"J0900B","text":"Date of first screening for pain:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.0.item.1","description":"When was the patient first screened for pain?"},{"linkId":"Section-10/J0900C","prefix":"J0900C","text":"The {patient's/resident's} pain severity was:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.2","description":"The severity of the patient's or resident's pain was:"},{"linkId":"Section-10/J0900D","prefix":"J0900D","text":"Type of standardized pain tool used:","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.0.item.3","description":"The type of standardized pain tool used for the patient is:"},{"linkId":"Section-10/J0905","prefix":"J0905","text":"Pain Active Problem. Is pain an active problem for the {patient/resident}?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.1","description":"Is pain an active problem for the patient or resident?"},{"linkId":"Section-10/J0910","prefix":"J0910","text":"Comprehensive Pain Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2"}],"id":"item.3.item.2","description":"The patient is required to fill out a comprehensive pain assessment."},{"linkId":"Section-10/J0910A","prefix":"J0910A","text":"Was a comprehensive pain assessment done?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.0","description":"Was a comprehensive pain assessment conducted on the patient?"},{"linkId":"Section-10/J0910B","prefix":"J0910B","text":"Date of comprehensive pain assessment:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.2.item.1","description":"When was the date of the patient's comprehensive pain assessment?"},{"linkId":"Section-10/J0910C","prefix":"J0910C","text":"Comprehensive pain assessment included: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.2.item.2","description":"The patient's form included a comprehensive pain assessment which stated: \"Check all that apply.\""},{"linkId":"Section-10/J2030","prefix":"J2030","text":"Screening for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2"}],"id":"item.3.item.3","description":"The patient is undergoing screening for shortness of breath."},{"linkId":"Section-10/J2030A","prefix":"J2030A","text":"Was the {patient/resident} screened for shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.0","description":"Was the patient or resident screened for symptoms of shortness of breath?"},{"linkId":"Section-10/J2030B","prefix":"J2030B","text":"Date of first screening for shortness of breath:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.3.item.1","description":"What was the date of the patient's first screening for shortness of breath?"},{"linkId":"Section-10/J2030C","prefix":"J2030C","text":"Did the screening indicate the {patient/resident} had shortness of breath?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.3.item.2","description":"Did the screening indicate that the patient had shortness of breath?"},{"linkId":"Section-10/J2040","prefix":"J2040","text":"Treatment for Shortness of Breath","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0"},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2"}],"id":"item.3.item.4","description":"What is the patient's treatment for shortness of breath?"},{"linkId":"Section-10/J2040A","prefix":"J2040A","text":"Was treatment for shortness of breath initiated? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.0","description":"Was the treatment for the patient's shortness of breath initiated? Please select the most accurate response."},{"linkId":"Section-10/J2040B","prefix":"J2040B","text":"Date treatment for shortness of breath initiated:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.3.item.4.item.1","description":"What is the date when the treatment for shortness of breath was initiated for the patient?"},{"linkId":"Section-10/J2040C","prefix":"J2040C","text":"Type(s) of treatment for shortness of breath initiated: Check all that apply","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.3.item.4.item.2","description":"What types of treatment for shortness of breath has the patient initiated? Please check all that apply."},{"linkId":"Section-14","text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/N0500","prefix":"N0500","text":"Scheduled Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1"}],"id":"item.4.item.0"},{"linkId":"Section-14/N0510","prefix":"N0510","text":"PRN Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0"},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1"}],"id":"item.4.item.1"},{"linkId":"Section-14/N0520","prefix":"N0520","text":"Bowel Regimen - Complete only if {scheduled opioid or PRN opioid = yes}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0"},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1"}],"id":"item.4.item.2"}],"id":"item.4","description":"In Section N of the form, the patient is asked to provide information about their medications."},{"linkId":"Section-14/N0500","prefix":"N0500","text":"Scheduled Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1"}],"id":"item.4.item.0","description":"Does the patient have a scheduled opioid medication regimen?"},{"linkId":"Section-14/N0500A","prefix":"N0500A","text":"Was a scheduled opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.0.item.0","description":"Did the patient have a scheduled opioid initiated or continued?"},{"linkId":"Section-14/N0500B","prefix":"N0500B","text":"Date scheduled opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.0.item.1","description":"The date the patient's opioid treatment was initiated or continued is scheduled for:"},{"linkId":"Section-14/N0510","prefix":"N0510","text":"PRN Opioid","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0"},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1"}],"id":"item.4.item.1","description":"Does the patient take opioid medication as needed?"},{"linkId":"Section-14/N0510A","prefix":"N0510A","text":"Was a PRN opioid initiated or continued?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.1.item.0","description":"Was a PRN opioid initiated or continued for the patient? The answer choices are: initiated, continued, or neither."},{"linkId":"Section-14/N0510B","prefix":"N0510B","text":"Date PRN opioid initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.1.item.1","description":"The date on which the patient's PRN opioid was initiated or continued."},{"linkId":"Section-14/N0520","prefix":"N0520","text":"Bowel Regimen - Complete only if {scheduled opioid or PRN opioid = yes}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0"},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1"}],"id":"item.4.item.2","description":"The patient should complete the section \"Bowel Regimen\" only if they are scheduled for opioid treatment or have been prescribed opioids on an as-needed basis."},{"linkId":"Section-14/N0520A","prefix":"N0520A","text":"Was a bowel regimen initiated or continued? - Select the most accurate response","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.4.item.2.item.0","description":"Was a bowel regimen initiated or continued for the patient? Please select the most accurate response."},{"linkId":"Section-14/N0520B","prefix":"N0520B","text":"Date bowel regimen initiated or continued:","type":"open-choice","repeats":false,"readOnly":false,"id":"item.4.item.2.item.1","description":"The date when the patient's bowel regimen was initiated or continued is required."},{"linkId":"Section-50","text":"Section O: Service Utilization","type":"group","readOnly":true,"item":[{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.0"}],"id":"item.5","description":"In Section O of the form, the patient's service utilization is assessed."},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.0","description":"What was the level of care the patient received in the final 3 days?"},{"linkId":"Section-48","text":"Section Z: Record Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0"},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1"}],"id":"item.6","description":"In section Z of the form, the administration records pertaining to the patient are documented."},{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0","description":"The signature of the person who completed the patient's assessment is required."},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0","description":"The patient is required to provide their signature, title, and date they completed section A."},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1","description":"The patient needs to provide their Signature, Title, ensure all Sections are filled out, and include the Date the Section was completed B."},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2","description":"The patient needs to provide their signature, title, and complete the sections required on the form. They should also include the date the section was completed, indicated as section C."},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3","description":"The patient filled out the signature, title, and sections, and completed section D on a specific date."},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4","description":"The sections of the form labeled \"Signature\", \"Title\", and \"Date Section Completed E\" should be filled out by the patient."},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5","description":"The form for the patient includes sections for signature, title, and the date when the section was completed."},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6","description":"The patient's signature, title, and the date the section was completed are all required in Section G."},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7","description":"The patient is required to provide their signature and title in the designated sections, and also specify the date when the section was completed."},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8","description":"The patient needs to provide their signature, title, and the sections they have completed on the form, along with the date the section was finished."},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9","description":"The patient is required to provide their signature, title, and date for each completed section on the form."},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10","description":"The patient is required to provide their signature, title, and date on the sections they have completed in Section K."},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11","description":"The patient must provide their signature, title, and date in the sections indicated upon completion."},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1","description":"The signature of the RN Coordinator is required to verify the completion of the patient's assessment."},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0","description":"The form requires the patient's signature."},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1","description":"The date on which the Registered Nurse Assessment Coordinator signed the patient's assessment as complete."},null],"_id":"srBxJJ4v8KcDF3tyy"} {"responseType":"QuestionnaireResponse","questionnaire":"HIS-HD-2.00.0","id":"HIS-HD-2.00.0-1","title":"Hospice Item Set - Hospice Discharge Record","description":"The HIS is a standardized set of items intended to capture patient-level data on each hospice patient admission. HIS items can be used to calculate seven National Quality Forum (NQF) - endorsed measures, and two non-NQF endorsed measures.","status":"draft","authored":"2024-09-20T06:33:39.936Z","item":[{"linkId":"Section-36","text":"Section A: Administrative Information","type":"group","readOnly":true,"item":[{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0"},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3"},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4"},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5"},{"linkId":"Section-36/A0270","prefix":"A0270","text":"Discharge Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.6"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1"}],"id":"item.0.item.7"},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3"}],"id":"item.0.item.8"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1"}],"id":"item.0.item.9"},{"linkId":"Section-36/A2115","prefix":"A2115","text":"Reason for Discharge","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.10"}],"id":"item.0","description":"The section A on the form is for administrative information about the patient."},{"linkId":"Section-36/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.0.item.0","description":"The form asks for the patient's Medicaid Number. They should enter \"+\" if their Medicaid application is pending, or \"N\" if they are not a Medicaid recipient."},{"linkId":"Section-36/A0800","prefix":"A0800","text":"Gender","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.1","description":"What is the patient's gender?"},{"linkId":"Section-36/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.2","description":"What is the patient's birth date?"},{"linkId":"Section-36/A0050","prefix":"A0050","text":"Type of Record","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.3","description":"The type of record pertaining to the patient needs to be identified."},{"linkId":"Section-36/A0250","prefix":"A0250","text":"Reason for Assessment","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.4","description":"The reason for the patient's assessment should be clearly specified."},{"linkId":"Section-36/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.5","description":"What is the patient's admission date?"},{"linkId":"Section-36/A0270","prefix":"A0270","text":"Discharge Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.0.item.6","description":"What is the patient's discharge date?"},{"linkId":"Section-36/A0100","prefix":"A0100","text":"Facility Provider Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1"}],"id":"item.0.item.7","description":"The facility has designated provider numbers for the patient."},{"linkId":"Section-36/A0100A","prefix":"A0100A","text":"National Provider Identifier (NPI)","type":"text","repeats":false,"readOnly":false,"maxLength":10,"id":"item.0.item.7.item.0","description":"What is the patient's National Provider Identifier (NPI)?"},{"linkId":"Section-36/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.7.item.1","description":"The patient needs to provide their CMS Certification Number (CCN)."},{"linkId":"Section-36/A0500","prefix":"A0500","text":"Legal Name of {Patient/Resident}","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3"}],"id":"item.0.item.8","description":"What is the legal name of the patient or resident?"},{"linkId":"Section-36/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.8.item.0","description":"What is the patient's first name?"},{"linkId":"Section-36/A0500B","prefix":"A0500B","text":"Middle initial","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.8.item.1","description":"What is the patient's middle initial?"},{"linkId":"Section-36/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.0.item.8.item.2","description":"What is the patient's last name?"},{"linkId":"Section-36/A0500D","prefix":"A0500D","text":"Suffix","type":"text","repeats":false,"readOnly":false,"maxLength":3,"id":"item.0.item.8.item.3","description":"What is the patient's suffix?"},{"linkId":"Section-36/A0600","prefix":"A0600","text":"Social Security and Medicare Numbers","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1"}],"id":"item.0.item.9","description":"The patient needs to provide their Social Security and Medicare numbers."},{"linkId":"Section-36/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.0.item.9.item.0","description":"What is the patient's Social Security Number?"},{"linkId":"Section-36/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.0.item.9.item.1","description":"What is the patient's Medicare number?"},{"linkId":"Section-36/A2115","prefix":"A2115","text":"Reason for Discharge","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.0.item.10","description":"What is the reason for the patient's discharge?"},{"linkId":"Section-47","text":"Section F: Preferences","type":"group","readOnly":true,"item":[{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR preference","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.1.item.0"}],"id":"item.1","description":"In section F of the form, the patient's preferences are to be indicated."},{"linkId":"Section-47/F2000","prefix":"F2000","text":"CPR preference","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.1.item.0","description":"What is the patient's preference regarding CPR?"},{"linkId":"Section-9","text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"}],"id":"item.2","description":"In Section I of the form, the active diagnoses of the patient are listed."},{"linkId":"Section-9/I0010","prefix":"I0010","text":"Principal diagnosis","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"The principal diagnosis for the patient is still undetermined."},{"linkId":"Section-10","text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J0100","prefix":"J0100","text":"Pain Management","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.3.item.0"}],"id":"item.3","description":"In Section J of the form, the patient is asked to provide information about their health conditions."},{"linkId":"Section-10/J0100","prefix":"J0100","text":"Pain Management","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.3.item.0","description":"Does the patient require pain management?"},{"linkId":"Section-14","text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/M2003","prefix":"M2003","text":"Medication follow-up","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.4.item.0"}],"id":"item.4","description":"In Section N of the form, it asks about the patient's medications."},{"linkId":"Section-14/M2003","prefix":"M2003","text":"Medication follow-up","type":"text","repeats":false,"readOnly":false,"maxLength":2,"id":"item.4.item.0","description":"Does the patient require a medication follow-up?"},{"linkId":"Section-50","text":"Section O: Service Utilization","type":"group","readOnly":true,"item":[{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.0"},{"linkId":"Section-50/O5010","prefix":"O5010","text":"Number of hospice visits in final 3 days. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0"},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1"},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2"}],"id":"item.5.item.1"},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Registered Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.2"},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"Registered Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.3"},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"Registered Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.4"},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.5"},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.6"},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.7"},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"Medical Social Worker - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.8"},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"Medical Social Worker - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.9"},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"Medical Social Worker - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.10"},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Chaplain or Spiritual Counselor - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.11"},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Chaplain or Spiritual Counselor -Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.12"},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Chaplain or Spiritual Counselor - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.13"},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Licensed Professional Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.14"},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Licensed Professional Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.15"},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Licensed Professional Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.16"},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Aide - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.17"},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Aide - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.18"},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Aide - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.19"},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Level of care in final 7 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.20"},{"linkId":"Section-50/O5030","prefix":"O5030","text":"Number of hospice visits in 3 to 6 days prior to death. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3"}],"id":"item.5.item.21"},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"Registered Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.22"},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"Registered Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.23"},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"Registered Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.24"},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"Registered Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.25"},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.26"},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.27"},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.28"},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.29"},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Medical Social Worker - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.30"},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"Medical Social Worker - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.31"},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"Medical Social Worker - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.32"},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"Medical Social Worker - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.33"},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Chaplain or Spiritual Counselor - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.34"},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"Chaplain or Spiritual Counselor - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.35"},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"Chaplain or Spiritual Counselor - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.36"},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Chaplain or Spiritual Counselor - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.37"},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"Licensed Professional Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.38"},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"Licensed Professional Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.39"},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Licensed Professional Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.40"},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"Licensed Professional Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.41"},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Aide - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.42"},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"Aide - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.43"},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Aide - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.44"},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Aide - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.45"}],"id":"item.5","description":"In section O of the form, the patient's service utilization is assessed."},{"linkId":"Section-50/O5000","prefix":"O5000","text":"Level of care in final 3 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.0","description":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final three days of their life?"},{"linkId":"Section-50/O5010","prefix":"O5010","text":"Number of hospice visits in final 3 days. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0"},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1"},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2"}],"id":"item.5.item.1","description":"The form requires the patient to enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated, specifically focusing on the final three days of hospice care."},{"linkId":"Section-50/O5010_1","prefix":"O5010_1","text":"Number of Hospice Visits - on Day of Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.0","description":"The number of hospice visits the patient had on the day of their death."},{"linkId":"Section-50/O5010_2","prefix":"O5010_2","text":"Number of Hospice Visits - One Day Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.1","description":"The form asked the patient how many hospice visits they had one day prior to their death."},{"linkId":"Section-50/O5010_3","prefix":"O5010_3","text":"Number of Hospice Visits - Two Days Prior to Death","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.1.item.2","description":"How many hospice visits did the patient have two days prior to death?"},{"linkId":"Section-50/O5010A1","prefix":"O5010A1","text":"Registered Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.2","description":"Did the registered nurse visit the patient on the day of death?"},{"linkId":"Section-50/O5010A2","prefix":"O5010A2","text":"Registered Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.3","description":"The registered nurse visited the patient one day prior to their death."},{"linkId":"Section-50/O5010A3","prefix":"O5010A3","text":"Registered Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.4","description":"Did the registered nurse visit the patient two days prior to their death?"},{"linkId":"Section-50/O5010B1","prefix":"O5010B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.5","description":"Did the patient receive a visit from a physician, nurse practitioner, or physician assistant on the day of their death?"},{"linkId":"Section-50/O5010B2","prefix":"O5010B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.6","description":"Did the patient have a visit from a physician, nurse practitioner, or physician assistant one day prior to their death?"},{"linkId":"Section-50/O5010B3","prefix":"O5010B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.7","description":"Did the patient visit a physician, nurse practitioner, or physician assistant two days prior to their death?"},{"linkId":"Section-50/O5010C1","prefix":"O5010C1","text":"Medical Social Worker - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.8","description":"Did the medical social worker visit the patient on the day of their death?"},{"linkId":"Section-50/O5010C2","prefix":"O5010C2","text":"Medical Social Worker - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.9","description":"The medical social worker visited the patient one day prior to their death."},{"linkId":"Section-50/O5010C3","prefix":"O5010C3","text":"Medical Social Worker - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.10","description":"The medical social worker visited the patient two days prior to their death."},{"linkId":"Section-50/O5010D1","prefix":"O5010D1","text":"Chaplain or Spiritual Counselor - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.11","description":"Did the patient receive a visit from a Chaplain or Spiritual Counselor on the day of their death?"},{"linkId":"Section-50/O5010D2","prefix":"O5010D2","text":"Chaplain or Spiritual Counselor -Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.12","description":"Did the patient receive a visit from a chaplain or spiritual counselor one day prior to their death?"},{"linkId":"Section-50/O5010D3","prefix":"O5010D3","text":"Chaplain or Spiritual Counselor - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.13","description":"Did the patient receive a visit from a chaplain or spiritual counselor two days prior to death?"},{"linkId":"Section-50/O5010E1","prefix":"O5010E1","text":"Licensed Professional Nurse - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.14","description":"Did the Licensed Professional Nurse visit the patient on the day of their death?"},{"linkId":"Section-50/O5010E2","prefix":"O5010E2","text":"Licensed Professional Nurse - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.15","description":"Did the licensed professional nurse visit the patient one day prior to their death?"},{"linkId":"Section-50/O5010E3","prefix":"O5010E3","text":"Licensed Professional Nurse - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.16","description":"The patient was visited by a Licensed Professional Nurse two days prior to their death."},{"linkId":"Section-50/O5010F1","prefix":"O5010F1","text":"Aide - Visits on day of death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.17","description":"Did the aide visit the patient on the day of death?"},{"linkId":"Section-50/O5010F2","prefix":"O5010F2","text":"Aide - Visits one day prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.18","description":"Did the aide visit the patient one day prior to their death?"},{"linkId":"Section-50/O5010F3","prefix":"O5010F3","text":"Aide - Visits two days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.19","description":"Did the patient receive an aide visit two days prior to death?"},{"linkId":"Section-50/O5020","prefix":"O5020","text":"Level of care in final 7 days. Did the {patient/resident} receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.20","description":"Did the patient or resident receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final seven days of their life?"},{"linkId":"Section-50/O5030","prefix":"O5030","text":"Number of hospice visits in 3 to 6 days prior to death. Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3"}],"id":"item.5.item.21","description":"The form is asking for the number of visits the patient received from hospice staff in the 3 to 6 days prior to their death. The respondent should enter the number of visits provided by hospice staff from the indicated discipline, on each of the specified dates."},{"linkId":"Section-50/O5030_1","prefix":"O5030_1","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Three Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.0","description":"How many hospice visits did the patient have three days prior to death?"},{"linkId":"Section-50/O5030_2","prefix":"O5030_2","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Four Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.1","description":"How many hospice visits did the patient have four days prior to death in the period of 3 to 6 days before death?"},{"linkId":"Section-50/O5030_3","prefix":"O5030_3","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Five Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.2","description":"How many hospice visits did the patient have five days prior to death?"},{"linkId":"Section-50/O5030_4","prefix":"O5030_4","text":"Number of Hospice Visits in 3 to 6 Days Prior to Death - Six Days Prior","type":"group","repeats":false,"readOnly":true,"id":"item.5.item.21.item.3","description":"How many hospice visits did the patient have in the six days prior to their death?"},{"linkId":"Section-50/O5030A1","prefix":"O5030A1","text":"Registered Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.22","description":"The patient was visited by a registered nurse three days prior to their death."},{"linkId":"Section-50/O5030A2","prefix":"O5030A2","text":"Registered Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.23","description":"The registered nurse visited the patient four days prior to their death."},{"linkId":"Section-50/O5030A3","prefix":"O5030A3","text":"Registered Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.24","description":"The registered nurse visited the patient five days prior to their death."},{"linkId":"Section-50/O5030A4","prefix":"O5030A4","text":"Registered Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.25","description":"The registered nurse visited the patient six days prior to their death."},{"linkId":"Section-50/O5030B1","prefix":"O5030B1","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.26","description":"Did the patient visit a physician, nurse practitioner, or physician assistant three days prior to death?"},{"linkId":"Section-50/O5030B2","prefix":"O5030B2","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.27","description":"The patient visited the physician, nurse practitioner, or physician assistant four days prior to their death."},{"linkId":"Section-50/O5030B3","prefix":"O5030B3","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.28","description":"Did the patient visit a physician, nurse practitioner, or physician assistant five days prior to their death?"},{"linkId":"Section-50/O5030B4","prefix":"O5030B4","text":"Physician (or Nurse Practitioner or Physician Assistant) - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.29","description":"The patient was visited by a physician, nurse practitioner, or physician assistant six days prior to death."},{"linkId":"Section-50/O5030C1","prefix":"O5030C1","text":"Medical Social Worker - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.30","description":"The medical social worker visited the patient three days prior to their death."},{"linkId":"Section-50/O5030C2","prefix":"O5030C2","text":"Medical Social Worker - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.31","description":"The medical social worker visited the patient four days prior to their death."},{"linkId":"Section-50/O5030C3","prefix":"O5030C3","text":"Medical Social Worker - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.32","description":"The medical social worker visited the patient five days prior to their death."},{"linkId":"Section-50/O5030C4","prefix":"O5030C4","text":"Medical Social Worker - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.33","description":"The medical social worker visited the patient six days prior to their death."},{"linkId":"Section-50/O5030D1","prefix":"O5030D1","text":"Chaplain or Spiritual Counselor - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.34","description":"Did the patient receive a visit from a chaplain or spiritual counselor three days prior to death?"},{"linkId":"Section-50/O5030D2","prefix":"O5030D2","text":"Chaplain or Spiritual Counselor - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.35","description":"Did the patient receive a visit from a chaplain or spiritual counselor four days prior to death?"},{"linkId":"Section-50/O5030D3","prefix":"O5030D3","text":"Chaplain or Spiritual Counselor - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.36","description":"Did the patient receive visits from a chaplain or spiritual counselor five days prior to death?"},{"linkId":"Section-50/O5030D4","prefix":"O5030D4","text":"Chaplain or Spiritual Counselor - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.37","description":"Did the patient receive a visit from a chaplain or spiritual counselor six days prior to death?"},{"linkId":"Section-50/O5030E1","prefix":"O5030E1","text":"Licensed Professional Nurse - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.38","description":"The licensed professional nurse visited the patient three days prior to their death."},{"linkId":"Section-50/O5030E2","prefix":"O5030E2","text":"Licensed Professional Nurse - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.39","description":"The Licensed Professional Nurse visited the patient four days prior to their death."},{"linkId":"Section-50/O5030E3","prefix":"O5030E3","text":"Licensed Professional Nurse - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.40","description":"The patient was visited by a licensed professional nurse five days prior to their death."},{"linkId":"Section-50/O5030E4","prefix":"O5030E4","text":"Licensed Professional Nurse - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.41","description":"The Licensed Professional Nurse visited the patient six days prior to their death."},{"linkId":"Section-50/O5030F1","prefix":"O5030F1","text":"Aide - Visits three days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.42","description":"The patient had visits from an aide three days prior to their death."},{"linkId":"Section-50/O5030F2","prefix":"O5030F2","text":"Aide - Visits four days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.43","description":"Did the aide visit the patient four days prior to death?"},{"linkId":"Section-50/O5030F3","prefix":"O5030F3","text":"Aide - Visits five days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.44","description":"Did the patient receive aid visits five days prior to death?"},{"linkId":"Section-50/O5030F4","prefix":"O5030F4","text":"Aide - Visits six days prior to death","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.5.item.45","description":"Did the aide visit the patient six days prior to death?"},{"linkId":"Section-48","text":"Section Z: Record Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0"},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1"}],"id":"item.6","description":"In Section Z, the record administration pertaining to the patient needs to be filled out."},{"linkId":"Section-48/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0"},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1"},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2"},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3"},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4"},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5"},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6"},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7"},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8"},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9"},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10"},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11"}],"id":"item.6.item.0","description":"The signature of the person who completed the patient's assessment is required."},{"linkId":"Section-48/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.0","description":"The patient needs to provide their signature, title, and the date on which they completed section A."},{"linkId":"Section-48/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.1","description":"The patient is required to provide their signature and title, and then complete section B, after which they must record the date the section was completed."},{"linkId":"Section-48/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.2","description":"The patient should provide their signature, title, and date in the section marked 'C'."},{"linkId":"Section-48/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.3","description":"The patient was required to provide their signature and title, fill out several sections, and note down the date they completed section D."},{"linkId":"Section-48/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.4","description":"\"The patient is required to provide a signature, title, and complete various sections. They also need to provide the date on which the section E was completed.\""},{"linkId":"Section-48/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.5","description":"The patient completed the sections of the form and signed it, indicating their title and date when they finished section F."},{"linkId":"Section-48/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.6","description":"The patient needs to provide their signature, title, and the date the sections were completed in Section G."},{"linkId":"Section-48/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.7","description":"The patient needs to provide their signature, title, and the date on which the form section H was completed."},{"linkId":"Section-48/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.8","description":"The patient is required to provide their signature, title, the sections they have completed, and the date on which the section was completed."},{"linkId":"Section-48/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.9","description":"The patient's form includes their signature, title, date, and the sections they completed, specifically section J."},{"linkId":"Section-48/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.10","description":"The patient is required to provide their signature, title, and the date on which the sections were completed."},{"linkId":"Section-48/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.0.item.11","description":"The form for the patient includes sections for a signature, title, and the date when the section was completed."},{"linkId":"Section-48/Z0500","prefix":"Z0500","text":"Signature of RN Coordinator Verifying Assessment Completion","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0"},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1"}],"id":"item.6.item.1","description":"The signature of the RN Coordinator is required to verify the completion of the patient's assessment."},{"linkId":"Section-48/Z0500A","prefix":"Z0500A","text":"Signature","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.6.item.1.item.0","description":"The form requires the patient's signature."},{"linkId":"Section-48/Z0500B","prefix":"Z0500B","text":"Date RN Assessment Coordinator signed assessment as complete","type":"open-choice","repeats":false,"readOnly":false,"id":"item.6.item.1.item.1","description":"The date when the Registered Nurse Assessment Coordinator signed the patient's assessment as complete."},null],"_id":"ZToSHDeLr4ijtxBFt"} {"responseType":"QuestionnaireResponse","questionnaire":"IRF-PAI-IA-3.0","id":"IRF-PAI-IA-3.0-1","title":"Inpatient Rehabilitation Facility Patient Assessment Instrument - IRF Admission","description":"Assessment data collected on all Medicare Part A fee-for-service patients who receive services under Part A from an inpatient rehabilitation facility (IRF) at admission and upon discharge.","status":"draft","authored":"2024-09-20T06:34:32.500Z","item":[{"linkId":"Section-45","text":"Discharge Information","type":"group","readOnly":true,"item":[{"linkId":"Section-45/40","prefix":"40","text":"Discharge date","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.0"}],"id":"item.0","description":"The patient's discharge information is ready to be reviewed."},{"linkId":"Section-45/40","prefix":"40","text":"Discharge date","type":"text","repeats":false,"readOnly":false,"maxLength":1,"id":"item.0.item.0","description":"What is the patient's discharge date?"},{"linkId":"Section-38","code":[{"system":"http://loinc.org","code":"85395-2","display":"IRF-PAI v3.0 - Identification information [CMS Assessment]"}],"text":"Identification Information","type":"group","readOnly":true,"item":[{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.0"},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.1"},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.1.item.2"},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.1.item.3"},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.4"},{"linkId":"Section-38/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.1.item.5"},{"linkId":"Section-38/A0800","prefix":"A0800","text":"Gender","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}],"id":"item.1.item.6"},{"linkId":"Section-38/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.7"},{"linkId":"Section-38/A1200","prefix":"A1200","text":"Marital Status","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}],"id":"item.1.item.8"},{"linkId":"Section-38/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.9"},{"linkId":"Section-38/11","prefix":"11","text":"Zip Code of {Patient's/Resident's} Pre-Hospital Residence","type":"text","repeats":false,"readOnly":false,"maxLength":5,"id":"item.1.item.10"},{"linkId":"Section-38/13","prefix":"13","text":"Assessment Reference Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.11"},{"linkId":"Section-38/14","prefix":"14","text":"Admission Class","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27331-0","display":"Initial rehab"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27332-8","display":"Evaluation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4395-5","display":"Readmission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27335-1","display":"Continuing rehabilitation"}}],"id":"item.1.item.12"},{"linkId":"Section-38/17","prefix":"17","text":"Pre-hospital Living With (Code only if item {Pre-hospital Living Setting} is Home)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27350-0","display":"Alone"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27351-8","display":"Family/Relatives"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27352-6","display":"Friends"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27353-4","display":"Attendant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}],"id":"item.1.item.13"},{"linkId":"Section-38/15A","prefix":"15A","text":"Admit From","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.14"},{"linkId":"Section-38/16A","prefix":"16A","text":"Pre-hospital Living Setting. Use codes from {Admit From}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.15"},{"linkId":"Section-38/1","prefix":"1","text":"{Facility/Provider} Information","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0"}],"id":"item.1.item.16"},{"linkId":"Section-38/5B","prefix":"5B","text":"{Patient/Resident} Identification Number","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.17"},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}],"id":"item.1.item.18"}],"id":"item.1","description":"The form requires the patient's identification information."},{"linkId":"Section-38/A0100B","prefix":"A0100B","text":"CMS Certification Number (CCN)","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.0","description":"What is the patient's CMS Certification Number (CCN)?"},{"linkId":"Section-38/A0500A","prefix":"A0500A","text":"First name","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.1","description":"What is the patient's first name?"},{"linkId":"Section-38/A0500C","prefix":"A0500C","text":"Last name","type":"text","repeats":false,"readOnly":false,"maxLength":18,"id":"item.1.item.2","description":"What is the patient's last name?"},{"linkId":"Section-38/A0600A","prefix":"A0600A","text":"Social Security Number","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.1.item.3","description":"What is the patient's Social Security Number?"},{"linkId":"Section-38/A0600B","prefix":"A0600B","text":"Medicare number","type":"text","repeats":false,"readOnly":false,"maxLength":12,"id":"item.1.item.4","description":"What is the patient's Medicare number?"},{"linkId":"Section-38/A0700","prefix":"A0700","text":"Medicaid Number - Enter \"+\" if pending, \"N\" if not a Medicaid recipient","type":"text","repeats":false,"readOnly":false,"maxLength":14,"id":"item.1.item.5","description":"The patient should enter a \"+\" in the section labeled \"Medicaid Number\" if their Medicaid application is pending, or a \"N\" if they are not a Medicaid recipient."},{"linkId":"Section-38/A0800","prefix":"A0800","text":"Gender","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA2-8","display":"Male"}},{"valueCoding":{"system":"http://loinc.org","code":"LA3-6","display":"Female"}}],"id":"item.1.item.6","description":"What is the patient's gender? The options are male, female, or other."},{"linkId":"Section-38/A0900","prefix":"A0900","text":"Birth Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.7","description":"What is the patient's birth date?"},{"linkId":"Section-38/A1200","prefix":"A1200","text":"Marital Status","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA47-6","display":"Never married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA48-4","display":"Married"}},{"valueCoding":{"system":"http://loinc.org","code":"LA49-2","display":"Widowed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4288-2","display":"Separated"}},{"valueCoding":{"system":"http://loinc.org","code":"LA51-8","display":"Divorced"}}],"id":"item.1.item.8","description":"What is the patient's marital status? Is they married, single, divorced, or widowed?"},{"linkId":"Section-38/A0220","prefix":"A0220","text":"Admission Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.9","description":"The admission date of the patient is when they were admitted to the hospital."},{"linkId":"Section-38/11","prefix":"11","text":"Zip Code of {Patient's/Resident's} Pre-Hospital Residence","type":"text","repeats":false,"readOnly":false,"maxLength":5,"id":"item.1.item.10","description":"What is the zip code of the patient's pre-hospital residence?"},{"linkId":"Section-38/13","prefix":"13","text":"Assessment Reference Date","type":"open-choice","repeats":false,"readOnly":false,"id":"item.1.item.11","description":"The assessment reference date for the patient has been set."},{"linkId":"Section-38/14","prefix":"14","text":"Admission Class","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://loinc.org","code":"LA27331-0","display":"Initial rehab"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27332-8","display":"Evaluation"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4395-5","display":"Readmission"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18068-9","display":"Unplanned discharge"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27335-1","display":"Continuing rehabilitation"}}],"id":"item.1.item.12","description":"The admission class for the patient is being determined."},{"linkId":"Section-38/17","prefix":"17","text":"Pre-hospital Living With (Code only if item {Pre-hospital Living Setting} is Home)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Alone"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27350-0","display":"Alone"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Family / Relatives"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27351-8","display":"Family/Relatives"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Friends"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27352-6","display":"Friends"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Attendant"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27353-4","display":"Attendant"}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Other"}},{"valueCoding":{"system":"http://loinc.org","code":"LA46-8","display":"Other"}}],"id":"item.1.item.13","description":"The patient's pre-hospital living situation should be coded only if the patient was living at home before hospitalization."},{"linkId":"Section-38/15A","prefix":"15A","text":"Admit From","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.14","description":"From where was the patient admitted?"},{"linkId":"Section-38/16A","prefix":"16A","text":"Pre-hospital Living Setting. Use codes from {Admit From}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Home (private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27336-9","display":"Home (private home/apt., board/care, assisted living, group home, transistional living)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27337-7","display":"Short-term General Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Skilled Nursing Facility (SNF)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27338-5","display":"Skilled nursing facility (SNF)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Intermediate Care"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27339-3","display":"Intermediate care"}},{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27340-1","display":"Home under care of organized home health service organization"}},{"valueCoding":{"system":"http://del.cms.gov","code":"50","display":"Hospice (Home)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27341-9","display":"Hospice (home)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Hospice (Institutional Facility)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27342-7","display":"Hospice (institutional facility)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"61","display":"Swing bed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10883-9","display":"Swing bed"}},{"valueCoding":{"system":"http://del.cms.gov","code":"62","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27344-3","display":"Another Inpatient Rehabilitation Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"63","display":"Long-Term Care Hospital (LTCH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10000-0","display":"Long-term care hospital (LTCH)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"64","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27346-8","display":"Medicaid Nursing Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"65","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27347-6","display":"Inpatient Psychiatric Facility"}},{"valueCoding":{"system":"http://del.cms.gov","code":"66","display":"Critical Access Hospital (CAH)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA22835-5","display":"Critical Access Hospital"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.1.item.15","description":"The pre-hospital living setting of the patient is determined by using codes from the 'Admit From' category."},{"linkId":"Section-38/1","prefix":"1","text":"{Facility/Provider} Information","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0"}],"id":"item.1.item.16","description":"The form contains a section for the patient to provide information about the facility or provider they are connected with.\n"},{"linkId":"Section-38/1A","prefix":"1A","text":"{Facility/Provider} Name","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.16.item.0","description":"What is the name of the facility or provider for the patient?"},{"linkId":"Section-38/5B","prefix":"5B","text":"{Patient/Resident} Identification Number","type":"text","repeats":false,"readOnly":false,"maxLength":50,"id":"item.1.item.17","description":"What is the patient's or resident's identification number?"},{"linkId":"Section-38/A1000","prefix":"A1000","text":"Race/Ethnicity: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6155-1","display":"American Indian or Alaska Native"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Asian"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6156-9","display":"Asian"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Black or African American"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10610-6","display":"Black or African American"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6214-6","display":"Hispanic or Latino"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10611-4","display":"Native Hawaiian or Other Pacific Islander"}},{"valueCoding":{"system":"http://del.cms.gov","code":"F","display":"White"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4457-3","display":"White"}}],"id":"item.1.item.18","description":"The patient should check all the boxes that apply to their race or ethnicity."},{"linkId":"Section-41","code":[{"system":"http://loinc.org","code":"87415-6","display":"IRF-PAI v3.0 - Medical Info [CMS Assessment]"}],"text":"Medical Information","type":"group","readOnly":true,"item":[{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Height (in inches). Record most recent height measure since {admission}","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0"},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"Weight (in pounds). Base weight on most recent measure in last {specify time period in days}; measure weight consistently, according to standard {facility/setting} practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer","repeats":false,"readOnly":false,"maxLength":3,"id":"item.2.item.1"},{"linkId":"Section-41/21A","prefix":"21A","text":"Impairment Group - Admission: Condition requiring admission to rehabilitation; code according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.2.item.2"},{"linkId":"Section-41/23","prefix":"23","text":"Date of Onset of Impairment","type":"open-choice","repeats":false,"readOnly":false,"id":"item.2.item.3"},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Are there any arthritis conditions recorded in items {impairment group, etiologic diagnosis, or comorbid conditions} that meet all the regulatory requirements for {IRF} classification","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.2.item.4"},{"linkId":"Section-41/22","prefix":"22","text":"Etiologic Diagnosis: (Use ICD codes to indicate the etiologic problem that led to the condition for which the {patient/resident} is receiving rehabilitation)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0"},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1"},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2"}],"id":"item.2.item.5"},{"linkId":"Section-41/24","prefix":"24","text":"Comorbid Conditions. Use ICD codes to enter comorbid medical conditions","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8"},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18"},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21"},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24"}],"id":"item.2.item.6"},{"linkId":"Section-41/21","prefix":"21","text":"Impairment group","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0"}],"id":"item.2.item.7"}],"id":"item.2","description":"The form is requesting the patient's medical information."},{"linkId":"Section-41/K0200A","prefix":"K0200A","text":"Height (in inches). Record most recent height measure since {admission}","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.2.item.0","description":"The form asks for the patient's height in inches and requests the most recent measurement since their admission."},{"linkId":"Section-41/K0200B","prefix":"K0200B","text":"Weight (in pounds). Base weight on most recent measure in last {specify time period in days}; measure weight consistently, according to standard {facility/setting} practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.)","type":"integer","repeats":false,"readOnly":false,"maxLength":3,"id":"item.2.item.1","description":"The patient's weight, in pounds, should be based on the most recent measurement taken within the specified time period in days. It's important to measure the patient's weight consistently, adhering to the standard practice of the facility or setting. For instance, this could be done in the morning after voiding, before a meal, with shoes off, and so on."},{"linkId":"Section-41/21A","prefix":"21A","text":"Impairment Group - Admission: Condition requiring admission to rehabilitation; code according to Appendix A.","type":"text","repeats":false,"readOnly":false,"maxLength":9,"id":"item.2.item.2","description":"The impairment group on the admission form refers to the condition that required the patient's admission to rehabilitation, which should be coded according to Appendix A."},{"linkId":"Section-41/23","prefix":"23","text":"Date of Onset of Impairment","type":"open-choice","repeats":false,"readOnly":false,"id":"item.2.item.3","description":"When did the patient's impairment begin?"},{"linkId":"Section-41/24A1","prefix":"24A1","text":"Are there any arthritis conditions recorded in items {impairment group, etiologic diagnosis, or comorbid conditions} that meet all the regulatory requirements for {IRF} classification","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.2.item.4","description":"Does the patient have any arthritis conditions recorded in the impairment group, etiologic diagnosis, or comorbid conditions that meet all the regulatory requirements for Inpatient Rehabilitation Facility (IRF) classification?"},{"linkId":"Section-41/22","prefix":"22","text":"Etiologic Diagnosis: (Use ICD codes to indicate the etiologic problem that led to the condition for which the {patient/resident} is receiving rehabilitation)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0"},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1"},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2"}],"id":"item.2.item.5","description":"The etiologic diagnosis requires the use of ICD codes to indicate the underlying problem that led to the condition for which the patient is receiving rehabilitation."},{"linkId":"Section-41/22A","prefix":"22A","text":"Etiologic Diagnosis A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.0","description":"The form for the patient includes a section labeled \"Etiologic Diagnosis A\"."},{"linkId":"Section-41/22B","prefix":"22B","text":"Etiologic Diagnosis B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.1","description":"The form for the patient includes a section labeled \"Etiologic Diagnosis B\"."},{"linkId":"Section-41/22C","prefix":"22C","text":"Etiologic Diagnosis C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.5.item.2","description":"The form asks for the patient's etiologic diagnosis C."},{"linkId":"Section-41/24","prefix":"24","text":"Comorbid Conditions. Use ICD codes to enter comorbid medical conditions","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8"},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18"},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21"},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24"}],"id":"item.2.item.6","description":"The patient is instructed to use ICD codes to enter their comorbid medical conditions under the section labeled \"Comorbid Conditions.\""},{"linkId":"Section-41/24A","prefix":"24A","text":"Comorbid Condition A","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.0","description":"Does the patient have a comorbid condition A?"},{"linkId":"Section-41/24B","prefix":"24B","text":"Comorbid Condition B","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.1","description":"Does the patient have Comorbid Condition B?"},{"linkId":"Section-41/24C","prefix":"24C","text":"Comorbid Condition C","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.2","description":"Does the patient have Comorbid Condition C?"},{"linkId":"Section-41/24D","prefix":"24D","text":"Comorbid Condition D","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.3","description":"Does the patient have any comorbid condition D?"},{"linkId":"Section-41/24E","prefix":"24E","text":"Comorbid Condition E","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.4","description":"Does the patient have a comorbid condition E?"},{"linkId":"Section-41/24F","prefix":"24F","text":"Comorbid Condition F","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.5","description":"Does the patient have a comorbid condition F?"},{"linkId":"Section-41/24G","prefix":"24G","text":"Comorbid Condition G","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.6","description":"Does the patient have comorbid condition G?"},{"linkId":"Section-41/24H","prefix":"24H","text":"Comorbid Condition H","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.7","description":"Does the patient have a comorbid condition H?"},{"linkId":"Section-41/24I","prefix":"24I","text":"Comorbid Condition I","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.8","description":"Does the patient have a comorbid condition? If yes, please specify."},{"linkId":"Section-41/24J","prefix":"24J","text":"Comorbid Condition J","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.9","description":"Does the patient have Comorbid Condition J?"},{"linkId":"Section-41/24K","prefix":"24K","text":"Comorbid Condition K","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.10","description":"Does the patient have a comorbid condition K?"},{"linkId":"Section-41/24L","prefix":"24L","text":"Comorbid Condition L","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.11","description":"Does the patient have any comorbid condition L?"},{"linkId":"Section-41/24M","prefix":"24M","text":"Comorbid Condition M","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.12","description":"Does the patient have a comorbid condition M?"},{"linkId":"Section-41/24N","prefix":"24N","text":"Comorbid Condition N","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.13","description":"Does the patient have a comorbid condition N?"},{"linkId":"Section-41/24O","prefix":"24O","text":"Comorbid Condition O","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.14","description":"Does the patient have any comorbid conditions?"},{"linkId":"Section-41/24P","prefix":"24P","text":"Comorbid Condition P","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.15","description":"Does the patient have a comorbid condition P?"},{"linkId":"Section-41/24Q","prefix":"24Q","text":"Comorbid Condition Q","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.16","description":"Does the patient have a comorbid condition?"},{"linkId":"Section-41/24R","prefix":"24R","text":"Comorbid Condition R","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.17","description":"Does the patient have a comorbid condition R?"},{"linkId":"Section-41/24S","prefix":"24S","text":"Comorbid Condition S","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.18","description":"The form asks if the patient has any comorbid conditions."},{"linkId":"Section-41/24T","prefix":"24T","text":"Comorbid Condition T","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.19","description":"Does the patient have a comorbid condition T?"},{"linkId":"Section-41/24U","prefix":"24U","text":"Comorbid Condition U","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.20","description":"Does the patient have a comorbid condition U?"},{"linkId":"Section-41/24V","prefix":"24V","text":"Comorbid Condition V","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.21","description":"Does the patient have a comorbid condition V? Please indicate yes or no."},{"linkId":"Section-41/24W","prefix":"24W","text":"Comorbid Condition W","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.22","description":"Does the patient have any comorbid condition W?"},{"linkId":"Section-41/24X","prefix":"24X","text":"Comorbid Condition X","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.23","description":"Does the patient have a comorbid condition X?"},{"linkId":"Section-41/24Y","prefix":"24Y","text":"Comorbid Condition Y","type":"text","repeats":false,"readOnly":false,"maxLength":8,"id":"item.2.item.6.item.24","description":"Does the patient have comorbid condition Y?"},{"linkId":"Section-41/21","prefix":"21","text":"Impairment group","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0"}],"id":"item.2.item.7","description":"What is the patient's impairment group?"},{"linkId":"Section-41/21_admission","prefix":"21_admission","text":"Impairment group - admission","type":"group","repeats":false,"readOnly":true,"id":"item.2.item.7.item.0","description":"What is the impairment group upon admission for the patient?"},{"linkId":"Section-40","code":[{"system":"http://loinc.org","code":"85401-8","display":"IRF-PAI - Payer information [CMS Assessment]"}],"text":"Payer Information","type":"group","readOnly":true,"item":[{"linkId":"Section-40/20","prefix":"20","text":"Payment Source","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0"},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1"}],"id":"item.3.item.0"}],"id":"item.3","description":"The form requires the patient's payer information."},{"linkId":"Section-40/20","prefix":"20","text":"Payment Source","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0"},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1"}],"id":"item.3.item.0","description":"The payment source for the patient is being determined."},{"linkId":"Section-40/20A","prefix":"20A","text":"Primary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.0","description":"The primary source of information regarding the patient's health condition is the patient themselves."},{"linkId":"Section-40/20B","prefix":"20B","text":"Secondary Source","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Medicare - Fee for Service"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27354-2","display":"Medicare Fee For Service"}},{"valueCoding":{"system":"http://del.cms.gov","code":"51","display":"Medicare - Medicare Advantage"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27355-9","display":"Medicare-Medicare Advantage"}},{"valueCoding":{"system":"http://del.cms.gov","code":"99","display":"Not Listed"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27349-2","display":"Not listed"}}],"id":"item.3.item.0.item.1","description":"The form for the patient includes a section titled \"Secondary Source.\""},{"linkId":"Section-2","code":[{"system":"http://loinc.org","code":"88522-8","display":"IRF-PAI v2.0 - Hearing, speech, and vision - admission [CMS Assessment]"}],"text":"Section B: Hearing, Speech, and Vision","type":"group","readOnly":true,"item":[{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}],"id":"item.4.item.0"},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}],"id":"item.4.item.1"}],"id":"item.4","description":"In Section B of the form, the patient's hearing, speech, and vision capabilities are assessed."},{"linkId":"Section-2/BB0700","prefix":"BB0700","text":"Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9967-6","display":"Expresses complex messages without difficulty and with speech that is clear and easy to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9966-8","display":"Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9972-6","display":"Frequently exhibits difficulty with expressing needs and ideas"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never expresses self or speech is very difficult to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11713-7","display":"Rarely/Never expresses self or speech is very difficult to understand"}}],"id":"item.4.item.0","description":"The patient's expression of ideas and wants, considering both verbal and non-verbal expression and excluding language barriers, should be evaluated. Does the patient often communicate their ideas and desires clearly? The answer could be 'Always', 'Often', 'Sometimes', 'Rarely', or 'Never'."},{"linkId":"Section-2/BB0800","prefix":"BB0800","text":"Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Understands: Clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10110-7","display":"Understands: clear comprehension without cues or repetitions"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10113-1","display":"Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10083-6","display":"Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Rarely/Never Understands"}},{"valueCoding":{"system":"http://loinc.org","code":"LA81-5","display":"Rarely/never understands"}}],"id":"item.4.item.1","description":"Does the patient understand both verbal and non-verbal content with the use of a hearing aid or device, if used, while excluding any language barriers?"},{"linkId":"Section-3","code":[{"system":"http://loinc.org","code":"88524-4","display":"IRF-PAI v2.0 - Cognitive patterns - admission [CMS Assessment]"}],"text":"Section C: Cognitive Patterns","type":"group","readOnly":true,"item":[{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all {patients/residents}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.5.item.0"},{"linkId":"Section-3/C0200","prefix":"C0200","text":"Repetition of Three Words - Ask {patient/resident}: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}],"id":"item.5.item.1"},{"linkId":"Section-3/C0500","prefix":"C0500","text":"BIMS Summary Score. Add scores for {Brief Interview for Mental Status questions} and fill in total score (00-15). Enter 99 if the {patient/resident} was unable to complete the interview","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.2"},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the Staff Assessment for Mental Status be Conducted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes ({patient/resident} was unable to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}],"id":"item.5.item.3"},{"linkId":"Section-3/C0300","prefix":"C0300","text":"BIMS: Temporal Orientation (orientation to year, month, and day)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0"},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1"},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2"}],"id":"item.5.item.4"},{"linkId":"Section-3/C0400","prefix":"C0400","text":"Recall. Ask {patient/resident}: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0"},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1"},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2"}],"id":"item.5.item.5"},{"linkId":"Section-3/C0900","prefix":"C0900","text":"Memory/Recall Ability: Check all that the {patient/resident} was normally able to recall","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above were recalled"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}],"id":"item.5.item.6"}],"id":"item.5","description":"In Section C of the form, the patient's cognitive patterns are assessed."},{"linkId":"Section-3/C0100","prefix":"C0100","text":"Should Brief Interview for Mental Status be Conducted? Attempt to conduct interview with all {patients/residents}","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} is rarely/never understood)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27578-6","display":"No (patient is rarely/never understood)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.5.item.0","description":"Should a Brief Interview for Mental Status be conducted? It is suggested to attempt to conduct the interview with all patients or residents."},{"linkId":"Section-3/C0200","prefix":"C0200","text":"Repetition of Three Words - Ask {patient/resident}: \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" Number of words repeated after first attempt","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Three"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6395-3","display":"Three"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Two"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6404-3","display":"Two"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"One"}},{"valueCoding":{"system":"http://loinc.org","code":"LA6306-0","display":"One"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"None"}},{"valueCoding":{"system":"http://loinc.org","code":"LA137-2","display":"None"}}],"id":"item.5.item.1","description":"The form asks the patient, \"I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.\" The number of words repeated after the first attempt is then recorded by the medical professional."},{"linkId":"Section-3/C0500","prefix":"C0500","text":"BIMS Summary Score. Add scores for {Brief Interview for Mental Status questions} and fill in total score (00-15). Enter 99 if the {patient/resident} was unable to complete the interview","type":"integer","repeats":false,"readOnly":false,"maxLength":2,"id":"item.5.item.2","description":"The BIMS Summary Score should be calculated by adding the scores for the Brief Interview for Mental Status questions and filling in the total score, which ranges from 00 to 15. If the patient or resident was unable to complete the interview, the score to be entered should be 99."},{"linkId":"Section-3/C0600","prefix":"C0600","text":"Should the Staff Assessment for Mental Status be Conducted?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No ({patient/resident} was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26843-5","display":"No (patient was able to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes ({patient/resident} was unable to complete Brief Interview for Mental Status)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26844-3","display":"Yes (patient was unable to complete Brief Interview for Mental Status)"}}],"id":"item.5.item.3","description":"Should the staff assessment for the patient's mental status be conducted?"},{"linkId":"Section-3/C0300","prefix":"C0300","text":"BIMS: Temporal Orientation (orientation to year, month, and day)","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0"},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1"},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2"}],"id":"item.5.item.4","description":"The patient's BIMS assessment includes a temporal orientation evaluation, which evaluates their orientation to the current year, month, and day."},{"linkId":"Section-3/C0300A","prefix":"C0300A","text":"Ask {patient/resident}: \"Please tell me what year it is right now.\" Able to report correct year","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10008-3","display":"Missed by 1 year"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 2 - 5 years"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10966-2","display":"Missed by 2-5 years"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 5 years or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10965-4","display":"Missed by > 5 years or no answer"}}],"id":"item.5.item.4.item.0","description":"The form asks the patient or resident, \"Please tell me what year it is right now.\" They are able to report the correct year."},{"linkId":"Section-3/C0300B","prefix":"C0300B","text":"Ask {patient/resident}: \"What month are we in right now?\" Able to report correct month","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9927-0","display":"Accurate within 5 days"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10010-9","display":"Missed by 6 days to 1 month"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Missed by > 1 month or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10969-6","display":"Missed by > 1 month or no answer"}}],"id":"item.5.item.4.item.1","description":"The form asks the patient or resident, \"What month are we in right now?\" The patient or resident should be able to report the correct month."},{"linkId":"Section-3/C0300C","prefix":"C0300C","text":"Ask {patient/resident}: \"What day of the week is today?\" Able to report correct day of the week","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Correct"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9960-1","display":"Correct"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Incorrect or no answer"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9981-7","display":"Incorrect or no answer"}}],"id":"item.5.item.4.item.2","description":"Ask the patient or resident: \"What day of the week is today?\" They should be able to report the correct day of the week."},{"linkId":"Section-3/C0400","prefix":"C0400","text":"Recall. Ask {patient/resident}: \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0"},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1"},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2"}],"id":"item.5.item.5","description":"The doctor asks the patient, \"Let's go back to an earlier question. What were those three words that I asked you to repeat?\" If the patient is unable to remember a word, the doctor gives a cue, such as 'something to wear', 'a color', or 'a piece of furniture', for that particular word."},{"linkId":"Section-3/C0400A","prefix":"C0400A","text":"Able to recall \"sock\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10126-3","display":"Yes, after cueing (\"something to wear\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.0","description":"The patient is able to recall the word \"sock\"."},{"linkId":"Section-3/C0400B","prefix":"C0400B","text":"Able to recall \"blue\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10978-7","display":"Yes, after cueing (\"a color\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.1","description":"The patient is able to recall the color \"blue\"."},{"linkId":"Section-3/C0400C","prefix":"C0400C","text":"Able to recall \"bed\"","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10134-7","display":"Yes, no cue required"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10125-5","display":"Yes, after cueing (\"a piece of furniture\")"}},{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - could not recall"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10974-6","display":"No - could not recall"}}],"id":"item.5.item.5.item.2","description":"Is the patient able to recall \"bed\"?"},{"linkId":"Section-3/C0900","prefix":"C0900","text":"Memory/Recall Ability: Check all that the {patient/resident} was normally able to recall","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Current season"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9962-7","display":"Current season"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Location of own room"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9998-1","display":"Location of own room"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Staff names and faces"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10085-1","display":"Staff names and faces"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26728-8","display":"That he or she is in a hospital/hospital unit"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above were recalled"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26729-6","display":"None of the above were recalled"}}],"id":"item.5.item.6","description":"The patient's or resident's ability to recall normally should be assessed. Please check all that apply."},{"linkId":"Section-37","code":[{"system":"http://loinc.org","code":"88482-5","display":"Functional abilities and goals - admission [CMS Assessment]"}],"text":"Section GG: Functional Abilities and Goals","type":"group","readOnly":true,"item":[{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.0"},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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If managing an ostomy, include wiping the opening but not managing equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.13"},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.14"},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.28"},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the {patient/resident} use a wheelchair and/or scooter? - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.6.item.29"},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.30"},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.31"},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.32"},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.33"},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.34"},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.35"},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.36"},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.37"},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. 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Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. 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Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.45"},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.46"},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.47"},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.48"},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"4 steps: The ability to go up and down four steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.49"},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.50"},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.51"},{"linkId":"Section-37/GG0100","prefix":"GG0100","text":"Prior Functioning: Everyday Activities. Indicate the {patient's/resident's} usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0"},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1"},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2"},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3"}],"id":"item.6.item.52"},{"linkId":"Section-37/GG0130","prefix":"GG0130","text":"Self-Care.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0"},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1"}],"id":"item.6.item.53"},{"linkId":"Section-37/GG0170","prefix":"GG0170","text":"Mobility.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0"},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1"}],"id":"item.6.item.54"},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Prior Device Use. Indicate devices and aids used by the {patient/resident} prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.6.item.55"}],"id":"item.6","description":"In Section GG of the form, the patient's functional abilities and goals are documented."},{"linkId":"Section-37/GG0130A1","prefix":"GG0130A1","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.0","description":"The question for the patient or resident is about their eating ability. Specifically, can they use suitable utensils to bring food and/or liquid to their mouth and swallow food and/or liquid once the meal is placed before them? This is in reference to their performance upon admission."},{"linkId":"Section-37/GG0130B1","prefix":"GG0130B1","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.1","description":"The form asks about the patient's oral hygiene, specifically their ability to use suitable items to clean their teeth. It also inquires if they have dentures and if so, their ability to insert and remove them from the mouth, as well as manage denture soaking and rinsing with the use of equipment. This is relevant to their admission performance."},{"linkId":"Section-37/GG0130C1","prefix":"GG0130C1","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.2","description":"The form asks about the patient's ability to maintain perineal hygiene and adjust their clothes before and after voiding or having a bowel movement. If the patient is managing an ostomy, it includes the task of wiping the opening but not managing the equipment. This is pertaining to their performance upon admission."},{"linkId":"Section-37/GG0130A2","prefix":"GG0130A2","text":"Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the {patient/resident}. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.3","description":"The discharge goal for the patient is to have the ability to use suitable utensils in order to bring food and/or liquid to their mouth and to be able to swallow food and/or liquid once the meal is placed before them."},{"linkId":"Section-37/GG0130B2","prefix":"GG0130B2","text":"Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.4","description":"The form inquires about the patient's oral hygiene: their ability to use suitable items to clean their teeth. It also asks if the patient has dentures and if so, it assesses their ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with the use of equipment. The goal is to prepare the patient for discharge."},{"linkId":"Section-37/GG0130C2","prefix":"GG0130C2","text":"Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.5","description":"The discharge goal for the patient is related to toileting hygiene, which refers to their ability to maintain perineal hygiene, adjust clothing before and after voiding or having a bowel movement. If they are managing an ostomy, this also includes wiping the opening, but not managing the equipment."},{"linkId":"Section-37/GG0170A1","prefix":"GG0170A1","text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.6","description":"The form asks about the patient's ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed, as part of their admission performance."},{"linkId":"Section-37/GG0170B1","prefix":"GG0170B1","text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.7","description":"The form asks about the patient's admission performance regarding their ability to move from sitting on the side of the bed to lying flat on the bed."},{"linkId":"Section-37/GG0170C1","prefix":"GG0170C1","text":"Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.8","description":"The form is asking about the patient's ability to move from lying on their back to sitting on the side of the bed without any back support. This is in reference to their admission performance."},{"linkId":"Section-37/GG0170A2","prefix":"GG0170A2","text":"Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.9","description":"The discharge goal for the patient is to acquire the ability to roll from lying on their back to their left and right side, and return to lying on their back on the bed."},{"linkId":"Section-37/GG0170B2","prefix":"GG0170B2","text":"Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.10","description":"The discharge goal for the patient is to have the ability to move from sitting on the side of the bed to lying flat on the bed."},{"linkId":"Section-37/GG0170C2","prefix":"GG0170C2","text":"Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.11","description":"The discharge goal for the patient is to have the ability to move from lying on their back to sitting on the side of the bed without any back support."},{"linkId":"Section-37/GG0170D1","prefix":"GG0170D1","text":"Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.12","description":"The form asks the patient about their ability to come to a standing position from sitting in a chair, a wheelchair, or on the side of the bed, and requests them to rate their admission performance."},{"linkId":"Section-37/GG0170E1","prefix":"GG0170E1","text":"Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.13","description":"The form is asking about the patient's ability to transfer to and from a bed to a chair or wheelchair. It is inquiring about their admission performance."},{"linkId":"Section-37/GG0170F1","prefix":"GG0170F1","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.14","description":"The form asks about the patient's ability to transfer to and from a toilet or commode on their own as it pertains to their performance upon admission."},{"linkId":"Section-37/GG0170I1","prefix":"GG0170I1","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.15","description":"The question on the form asks about the patient's admission performance in relation to their ability to walk. Specifically, it inquires whether, once standing, the patient can walk at least 10 feet in a room, corridor, or similar space."},{"linkId":"Section-37/GG0170J1","prefix":"GG0170J1","text":"Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.16","description":"Once standing, the patient has the ability to walk at least 50 feet and make two turns as part of their admission performance."},{"linkId":"Section-37/GG0170K1","prefix":"GG0170K1","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.17","description":"The form inquires about the patient's capability to walk at least 150 feet in a corridor or similar space once they are standing. This is referred to as the \"Admission Performance\" aspect."},{"linkId":"Section-37/GG0170R1","prefix":"GG0170R1","text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.18","description":"Once the patient is seated in the wheelchair or scooter, they should have the ability to wheel at least 50 feet and make two turns. This is a requirement for admission performance."},{"linkId":"Section-37/GG0170S1","prefix":"GG0170S1","text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.19","description":"The admission performance form includes a question regarding the patient's ability, once seated in a wheelchair or scooter, to wheel at least 150 feet in a corridor or similar space."},{"linkId":"Section-37/GG0170K3","prefix":"GG0170K3","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Discharge Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.20","description":"The form asks about the patient's ability to walk at least 150 feet in a corridor or similar space once they are standing, with the label of \"Discharge Performance\"."},{"linkId":"Section-37/GG0170D2","prefix":"GG0170D2","text":"Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.21","description":"The discharge goal for the patient is to develop the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed."},{"linkId":"Section-37/GG0170E2","prefix":"GG0170E2","text":"Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.22","description":"The form asks about the patient's ability to transfer themselves to and from a bed to a chair or wheelchair. The discharge goal is to evaluate this capability."},{"linkId":"Section-37/GG0170F2","prefix":"GG0170F2","text":"Toilet transfer: The ability to get on and off a toilet or commode. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.23","description":"The discharge goal for the patient refers to their ability to independently get on and off a toilet or commode."},{"linkId":"Section-37/GG0170I2","prefix":"GG0170I2","text":"Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.24","description":"The question on the form is asking about the patient's ability, once standing, to walk at least 10 feet in a room, corridor, or similar space. The goal is that the patient should be able to do this upon discharge."},{"linkId":"Section-37/GG0170J2","prefix":"GG0170J2","text":"Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.25","description":"The label is asking about the patient's ability, once standing, to walk a minimum of 50 feet and make two turns. The goal is to achieve this by the time of discharge."},{"linkId":"Section-37/GG0170K2","prefix":"GG0170K2","text":"Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.26","description":"The form asks if the patient, once standing, has the ability to walk at least 150 feet in a corridor or similar space. The response options for this question are 'discharge goal'."},{"linkId":"Section-37/GG0170R2","prefix":"GG0170R2","text":"Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.27","description":"The discharge goal for the patient is to be able to wheel at least 50 feet and make two turns once seated in a wheelchair or scooter."},{"linkId":"Section-37/GG0170S2","prefix":"GG0170S2","text":"Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.28","description":"The discharge goal for the patient is to gain the ability to wheel at least 150 feet in a corridor or similar space once seated in a wheelchair or scooter."},{"linkId":"Section-37/GG0170Q1","prefix":"GG0170Q1","text":"Does the {patient/resident} use a wheelchair and/or scooter? - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.6.item.29","description":"Does the patient or resident use a wheelchair and/or scooter upon admission?"},{"linkId":"Section-37/GG0170RR1","prefix":"GG0170RR1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.30","description":"The form is asking the patient to indicate the type of wheelchair or scooter they use upon admission."},{"linkId":"Section-37/GG0170SS1","prefix":"GG0170SS1","text":"Indicate the type of wheelchair or scooter used. - Admission","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Manual"}},{"valueCoding":{"system":"http://loinc.org","code":"LA19016-7","display":"Manual"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Motorized"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26847-6","display":"Motorized"}}],"id":"item.6.item.31","description":"The form asks the patient to indicate the type of wheelchair or scooter they use upon admission."},{"linkId":"Section-37/GG0130E1","prefix":"GG0130E1","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.32","description":"The form asks about the patient's ability to shower or bathe themselves, which includes tasks such as washing, rinsing, and drying themselves, but does not include washing their back and hair, nor transferring in and out of the tub or shower. The question relates to their performance upon admission."},{"linkId":"Section-37/GG0130F1","prefix":"GG0130F1","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.33","description":"The admission form inquires about the patient's ability to dress and undress above the waist, including handling fasteners if applicable, in the section labeled \"Upper body dressing.\""},{"linkId":"Section-37/GG0130G1","prefix":"GG0130G1","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.34","description":"On the admission performance form, there is a question about the patient's ability to dress and undress below the waist, including handling fasteners. This does not include dealing with footwear."},{"linkId":"Section-37/GG0130H1","prefix":"GG0130H1","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.35","description":"Does the patient have the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable? Please evaluate their performance upon admission."},{"linkId":"Section-37/GG0170G1","prefix":"GG0170G1","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.36","description":"On the admission form, it asks about the patient's ability to transfer in and out of a car or van on the passenger side, without including the ability to open or close the door or fasten the seat belt."},{"linkId":"Section-37/GG0170L1","prefix":"GG0170L1","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.37","description":"The form asks if the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, either indoors or outdoors. This is in reference to their admission performance."},{"linkId":"Section-37/GG0170M1","prefix":"GG0170M1","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.38","description":"The form asks about the patient's ability to go up and down a curb and/or up and down one step in regards to their admission performance."},{"linkId":"Section-37/GG0170N1","prefix":"GG0170N1","text":"4 steps: The ability to go up and down four steps with or without a rail. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.39","description":"The form asks about the patient's ability to go up and down four steps with or without a rail in terms of admission performance."},{"linkId":"Section-37/GG0170O1","prefix":"GG0170O1","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.40","description":"The form asks whether the patient has the ability to go up and down 12 steps with or without a rail as part of their admission performance."},{"linkId":"Section-37/GG0170P1","prefix":"GG0170P1","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Admission Performance","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.41","description":"The form asks about the patient's admission performance in terms of their ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor."},{"linkId":"Section-37/GG0130E2","prefix":"GG0130E2","text":"Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.42","description":"The discharge goal for the patient is to be able to shower or bathe themselves. This means the patient should have the ability to wash, rinse, and dry themselves, excluding washing of the back and hair. It does not include transferring in or out of the tub or shower."},{"linkId":"Section-37/GG0130F2","prefix":"GG0130F2","text":"Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.43","description":"The discharge goal for the patient is to be able to dress and undress above the waist, which includes handling any fasteners, if applicable, on their own."},{"linkId":"Section-37/GG0130G2","prefix":"GG0130G2","text":"Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.44","description":"The discharge goal for the patient is to be able to independently dress and undress their lower body, below the waist, including handling fasteners, but not including footwear."},{"linkId":"Section-37/GG0130H2","prefix":"GG0130H2","text":"Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.45","description":"The form asks about the patient's ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility, including fasteners if applicable, and what the discharge goal for this ability is."},{"linkId":"Section-37/GG0170G2","prefix":"GG0170G2","text":"Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.46","description":"The discharge goal for the patient is to have the ability to transfer in and out of a car or van on the passenger side. This does not include the ability to open or close the door or fasten their seat belt."},{"linkId":"Section-37/GG0170L2","prefix":"GG0170L2","text":"Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.47","description":"The form asks if the patient has the ability to walk 10 feet on uneven or sloping surfaces, such as turf or gravel, indoor or outdoor, with the discharge goal being the endpoint."},{"linkId":"Section-37/GG0170M2","prefix":"GG0170M2","text":"1 step (curb): The ability to go up and down a curb and/or up and down one step. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.48","description":"The question on the form asks about the patient's ability to go up and down a curb and/or up and down one step. The label for this section is \"Discharge Goal\"."},{"linkId":"Section-37/GG0170N2","prefix":"GG0170N2","text":"4 steps: The ability to go up and down four steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.49","description":"The discharge goal for the patient is to have the ability to go up and down four steps with or without a rail."},{"linkId":"Section-37/GG0170O2","prefix":"GG0170O2","text":"12 steps: The ability to go up and down 12 steps with or without a rail. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.50","description":"The discharge goal for the patient is to develop the ability to go up and down 12 steps with or without the use of a rail."},{"linkId":"Section-37/GG0170P2","prefix":"GG0170P2","text":"Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. - Discharge Goal","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"06","display":"Independent - {Patient/Resident} completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA9983-3","display":"Independent - Patient completes the activity by themself with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"05","display":"Setup or clean-up assistance - Helper sets up or cleans up; {patient/resident} completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10073-7","display":"Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"04","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as {patient/resident} completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28225-3","display":"Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently."}},{"valueCoding":{"system":"http://del.cms.gov","code":"03","display":"Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10055-4","display":"Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"02","display":"Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11759-0","display":"Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort."}},{"valueCoding":{"system":"http://del.cms.gov","code":"01","display":"Dependent - Helper does ALL of the effort. {Patient/Resident} does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the {patient/resident} to complete the activity."}},{"valueCoding":{"system":"http://loinc.org","code":"LA27665-1","display":"Dependent - Helper does all of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity."}},{"valueCoding":{"system":"http://del.cms.gov","code":"07","display":"{Patient/Resident} refused"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10058-8","display":"Patient refused"}},{"valueCoding":{"system":"http://del.cms.gov","code":"09","display":"Not applicable - Not attempted and the {patient/resident} did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://loinc.org","code":"LA28226-1","display":"Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury."}},{"valueCoding":{"system":"http://del.cms.gov","code":"10","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA28227-9","display":"Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)."}},{"valueCoding":{"system":"http://del.cms.gov","code":"88","display":"Not attempted due to medical condition or safety concerns"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26735-3","display":"Not attempted due to medical condition or safety concerns"}}],"id":"item.6.item.51","description":"The discharge goal for the patient is to have the ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor."},{"linkId":"Section-37/GG0100","prefix":"GG0100","text":"Prior Functioning: Everyday Activities. Indicate the {patient's/resident's} usual ability with everyday activities prior to the current illness, exacerbation, or injury","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0"},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1"},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2"},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3"}],"id":"item.6.item.52","description":"Please indicate the patient's usual ability with everyday activities prior to their current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0100A","prefix":"GG0100A","text":"Self-Care: Code the {patient's/resident's} need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.0","description":"Please code the patient's or resident's need for assistance with bathing, dressing, using the toilet, and eating prior to their current illness, exacerbation, or injury for the Self-Care section."},{"linkId":"Section-37/GG0100B","prefix":"GG0100B","text":"Indoor Mobility (Ambulation): Code the {patient's/resident's} need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.1","description":"The form requests the code for the patient's or resident's need for assistance with walking from room to room, with or without a device such as a cane, crutch, or walker, prior to the current illness, exacerbation, or injury to determine their level of indoor mobility and ambulation."},{"linkId":"Section-37/GG0100C","prefix":"GG0100C","text":"Stairs: Code the {patient's/resident's} need for assistance with internal or external stairs (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.2","description":"The form asks to code the patient's or resident's need for assistance with internal or external stairs, with or without a device such as a cane, crutch, or walker, prior to the current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0100D","prefix":"GG0100D","text":"Functional Cognition: Code the {patient's/resident's} need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Independent - {Patient/Resident} completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11539-6","display":"Independent - Patient completed all the activities by themself, with or without an assistive device, with no assistance from a helper."}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Needed Some Help - {Patient/Resident} needed partial assistance from another person to complete any activities."}},{"valueCoding":{"system":"http://loinc.org","code":"LA26832-8","display":"Needed some help - Patient needed partial assistance from another person to complete activities."}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Dependent - A helper completed all the activities for the {patient/resident}."}},{"valueCoding":{"system":"http://loinc.org","code":"LA11541-2","display":"Dependent - A helper completed the activities for the patient."}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not Applicable"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4720-4","display":"Not applicable"}}],"id":"item.6.item.52.item.3","description":"The form asks to code the patient's or resident's need for assistance with planning regular tasks, such as shopping or remembering to take medication, prior to their current illness, exacerbation, or injury."},{"linkId":"Section-37/GG0130","prefix":"GG0130","text":"Self-Care.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0"},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1"}],"id":"item.6.item.53","description":"The patient is capable of self-care."},{"linkId":"Section-37/GG0130_1","prefix":"GG0130_1","text":"Self-Care. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.0","description":"For the category of Self-Care, please code the patient's usual performance at the time of admission for each activity using the 6-point scale. If the activity was not attempted at the time of admission, please code the reason."},{"linkId":"Section-37/GG0130_2","prefix":"GG0130_2","text":"Self-Care. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.53.item.1","description":"Please code the patient's or resident's self-care discharge goals using the 6-point scale. The use of codes 07, 09, 10, or 88 is permissible to code the discharge goals."},{"linkId":"Section-37/GG0170","prefix":"GG0170","text":"Mobility.","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0"},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1"}],"id":"item.6.item.54","description":"The patient's mobility status is being assessed."},{"linkId":"Section-37/GG0170_1","prefix":"GG0170_1","text":"Mobility. Code the {patient's/resident's} usual performance at {admission} for each activity using the 6-point scale. If activity was not attempted at {admission}, code the reason.","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.0","description":"For the section on mobility, please code the patient's or resident's usual performance at the time of admission for each activity using the 6-point scale. If a certain activity was not attempted at the time of admission, code the reason."},{"linkId":"Section-37/GG0170_2","prefix":"GG0170_2","text":"Mobility. Code the {patient's/resident's} {discharge} goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code {discharge} goal(s).","type":"group","repeats":false,"readOnly":true,"id":"item.6.item.54.item.1","description":"The form instructs the user to code the patient's or resident's discharge goals using the 6-point scale. The use of codes 07, 09, 10, or 88 is permissible to code the discharge goals."},{"linkId":"Section-37/GG0110","prefix":"GG0110","text":"Prior Device Use. Indicate devices and aids used by the {patient/resident} prior to the current illness, exacerbation, or injury: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18363-4","display":"Manual wheelchair"}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26730-4","display":"Motorized wheelchair and/or scooter"}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Mechanical lift"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11549-5","display":"Mechanical lift"}},{"valueCoding":{"system":"http://del.cms.gov","code":"D","display":"Walker"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10117-2","display":"Walker"}},{"valueCoding":{"system":"http://del.cms.gov","code":"E","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10046-3","display":"Orthotics/Prosthetics"}},{"valueCoding":{"system":"http://del.cms.gov","code":"Z","display":"None of the above"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.6.item.55","description":"Please indicate the devices and aids that the patient or resident used prior to their current illness, exacerbation, or injury. Check all that apply."},{"linkId":"Section-8","code":[{"system":"http://loinc.org","code":"83237-8","display":"Bladder and bowel [CMS Assessment]"}],"text":"Section H: Bladder and Bowel","type":"group","readOnly":true,"item":[{"linkId":"Section-8/H0400","prefix":"H0400","text":"Bowel Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}],"id":"item.7.item.0"},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Bladder Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}],"id":"item.7.item.1"}],"id":"item.7","description":"In section H of the form, the patient's bladder and bowel conditions are addressed."},{"linkId":"Section-8/H0400","prefix":"H0400","text":"Bowel Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11042-1","display":"Always continent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11048-8","display":"Occasionally incontinent (one episode of bowel incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11049-6","display":"Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11050-4","display":"Always incontinent (no episodes of continent bowel movements)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not rated, {patient/resident} had an ostomy or did not have a bowel movement for the entire 3 days"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26835-1","display":"Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days"}}],"id":"item.7.item.0","description":"Please select the one category that best describes the bowel continence of the patient or resident."},{"linkId":"Section-8/H0350","prefix":"H0350","text":"Bladder Continence - Select the one category that best describes the {patient/resident}.","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26833-6","display":"Always continent (no documented incontinence)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26736-1","display":"Stress incontinence only"}},{"valueCoding":{"system":"http://del.cms.gov","code":"2","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26834-4","display":"Incontinent less than daily (e.g., once or twice during the 3-day assessment period)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"3","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9979-1","display":"Incontinent daily (at least once a day)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"4","display":"Always incontinent"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9934-6","display":"Always incontinent"}},{"valueCoding":{"system":"http://del.cms.gov","code":"5","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26738-7","display":"No urine output (e.g., renal failure)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable (e.g., indwelling catheter)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA11693-1","display":"Not applicable (e.g., indwelling catheter)"}}],"id":"item.7.item.1","description":"Please select the one category that best describes the patient's or resident's bladder continence."},{"linkId":"Section-9","code":[{"system":"http://loinc.org","code":"83264-2","display":"IRF-PAI - Active diagnoses [CMS Assessment]"}],"text":"Section I: Active Diagnoses","type":"group","readOnly":true,"item":[{"linkId":"Section-9/I0000","prefix":"I0000","text":"Active Diagnoses in the last 7 days: Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.8.item.0"}],"id":"item.8","description":"In Section I of the form, the patient's active diagnoses are listed."},{"linkId":"Section-9/I0000","prefix":"I0000","text":"Active Diagnoses in the last 7 days: Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"I0900","display":"Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA18399-8","display":"Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I2900","display":"Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://loinc.org","code":"LA26741-1","display":"Diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)"}},{"valueCoding":{"system":"http://del.cms.gov","code":"I7900","display":"None of the above active diagnoses"}},{"valueCoding":{"system":"http://loinc.org","code":"LA9-3","display":"None of the above"}}],"id":"item.8.item.0","description":"The patient has been asked to indicate all of their active diagnoses from the last 7 days on the form. They should check all that apply. The diagnoses provided in parentheses are just examples and should not be considered as an all-inclusive list."},{"linkId":"Section-10","code":[{"system":"http://loinc.org","code":"83273-3","display":"IRF-PAI - Health conditions - admission [CMS Assessment]"}],"text":"Section J: Health Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-10/J1750","prefix":"J1750","text":"History of Falls: Has the {patient/resident} had two or more falls in the past year or any fall with injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.0"},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Prior Surgery. Did the {patient/resident} have major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.1"}],"id":"item.9","description":"In Section J of the form, the patient's health conditions are being evaluated."},{"linkId":"Section-10/J1750","prefix":"J1750","text":"History of Falls: Has the {patient/resident} had two or more falls in the past year or any fall with injury in the past year?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.0","description":"Does the patient or resident have a history of having two or more falls in the past year, or any fall that resulted in injury in the past year?"},{"linkId":"Section-10/J2000","prefix":"J2000","text":"Prior Surgery. Did the {patient/resident} have major surgery during the 100 days prior to admission?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}},{"valueCoding":{"system":"http://del.cms.gov","code":"8","display":"Unknown"}},{"valueCoding":{"system":"http://loinc.org","code":"LA4489-6","display":"Unknown"}}],"id":"item.9.item.1","description":"Did the patient or resident have any major surgery during the 100 days prior to their admission?"},{"linkId":"Section-11","code":[{"system":"http://loinc.org","code":"83244-4","display":"IRF-PAI v2.0 - Swallowing/nutritional status - admission [CMS Assessment]"}],"text":"Section K: Swallowing/Nutritional Status","type":"group","readOnly":true,"item":[{"linkId":"Section-11/K0110","prefix":"K0110","text":"Swallowing/Nutritional Status. Indicate the {patient's/resident's} usual ability to swallow: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Regular food - Solids and liquids swallowed safely without supervision or modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Modified food consistency/supervision - {Patient/Resident} requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Tube/parenteral feeding - Tube/parenteral feeding used wholly or partially as a means of sustenance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}],"id":"item.10.item.0"}],"id":"item.10","description":"In Section K of the form, the patient's swallowing and nutritional status is assessed."},{"linkId":"Section-11/K0110","prefix":"K0110","text":"Swallowing/Nutritional Status. Indicate the {patient's/resident's} usual ability to swallow: Check all that apply","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"A","display":"Regular food - Solids and liquids swallowed safely without supervision or modified food or liquid consistency."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10070-3","display":"Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency."}},{"valueCoding":{"system":"http://del.cms.gov","code":"B","display":"Modified food consistency/supervision - {Patient/Resident} requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10013-3","display":"Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety."}},{"valueCoding":{"system":"http://del.cms.gov","code":"C","display":"Tube/parenteral feeding - Tube/parenteral feeding used wholly or partially as a means of sustenance."}},{"valueCoding":{"system":"http://loinc.org","code":"LA10103-2","display":"Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance."}}],"id":"item.10.item.0","description":"Please indicate the patient's usual ability to swallow regarding their swallowing or nutritional status. Check all that apply."},{"linkId":"Section-13","code":[{"system":"http://loinc.org","code":"85055-2","display":"IRF-PAI v3.0, LCDS v4.00 - Skin conditions - admission [CMS Assessment]"}],"text":"Section M: Skin Conditions","type":"group","readOnly":true,"item":[{"linkId":"Section-13/M0210","prefix":"M0210","text":"Unhealed Pressure Ulcers/Injuries. Does this {patient/resident} have one or more unhealed pressure ulcers/injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.11.item.0"},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"Number of Stage 2 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.1"},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"Number of Stage 3 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.2"},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"Number of Stage 4 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.3"},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.4"},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.5"},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.6"},{"linkId":"Section-13/M0300","prefix":"M0300","text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0"},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1"},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2"},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3"},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4"},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5"},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6"}],"id":"item.11.item.7"},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"Number of Stage 1 pressure injuries","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.8"}],"id":"item.11","description":"In Section M of the form, the patient's skin conditions are addressed."},{"linkId":"Section-13/M0210","prefix":"M0210","text":"Unhealed Pressure Ulcers/Injuries. Does this {patient/resident} have one or more unhealed pressure ulcers/injuries?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.11.item.0","description":"Does this patient or resident have one or more unhealed pressure ulcers or injuries?"},{"linkId":"Section-13/M0300B1","prefix":"M0300B1","text":"Number of Stage 2 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.1","description":"The patient has how many Stage 2 pressure ulcers?"},{"linkId":"Section-13/M0300C1","prefix":"M0300C1","text":"Number of Stage 3 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.2","description":"How many stage 3 pressure ulcers does the patient have?"},{"linkId":"Section-13/M0300D1","prefix":"M0300D1","text":"Number of Stage 4 pressure ulcers","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.3","description":"The patient has a certain number of Stage 4 pressure ulcers."},{"linkId":"Section-13/M0300E1","prefix":"M0300E1","text":"Number of unstageable pressure ulcers/injuries due to non-removable dressing/device","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.4","description":"How many unstageable pressure ulcers/injuries does the patient have due to a non-removable dressing/device?"},{"linkId":"Section-13/M0300F1","prefix":"M0300F1","text":"Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.5","description":"How many unstageable pressure ulcers does the patient have due to coverage of the wound bed by slough and/or eschar?"},{"linkId":"Section-13/M0300G1","prefix":"M0300G1","text":"Number of unstageable pressure injuries presenting as deep tissue injury","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.6","description":"The patient has a certain number of unstageable pressure injuries that present as deep tissue injury."},{"linkId":"Section-13/M0300","prefix":"M0300","text":"Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0"},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1"},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2"},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3"},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4"},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5"},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6"}],"id":"item.11.item.7","description":"The form is asking for the current number of unhealed pressure ulcers/injuries at each stage that the patient has."},{"linkId":"Section-13/M0300A","prefix":"M0300A","text":"Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.0","description":"The patient's condition is at Stage 1, where there is intact skin with non-blanchable redness of a localized area, usually over a bony prominence. It is noted that darkly pigmented skin may not exhibit visible blanching. In such cases, dark skin tones may only appear with persistent blue or purple hues."},{"linkId":"Section-13/M0300B","prefix":"M0300B","text":"Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.1","description":"The patient is at stage 2, which indicates a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. This may also present as an intact or open/ruptured blister."},{"linkId":"Section-13/M0300C","prefix":"M0300C","text":"Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.2","description":"The patient is at stage 3, which indicates full thickness tissue loss. At this stage, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but it does not obscure the depth of tissue loss. This stage may also include undermining and tunneling."},{"linkId":"Section-13/M0300D","prefix":"M0300D","text":"Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.3","description":"The patient has stage 4 skin integrity, characterized by full thickness tissue loss with exposed bone, tendon, or muscle. There may be slough or eschar present on some parts of the wound bed, and the condition often includes undermining and tunneling."},{"linkId":"Section-13/M0300E","prefix":"M0300E","text":"Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.4","description":"The patient has an unstageable condition due to a non-removable dressing or device, although the exact stage is known but cannot be identified because of the non-removable dressing or device."},{"linkId":"Section-13/M0300F","prefix":"M0300F","text":"Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.5","description":"The patient has a known, but unstageable wound due to the coverage of the wound bed by slough and/or eschar."},{"linkId":"Section-13/M0300G","prefix":"M0300G","text":"Unstageable - Deep tissue injury","type":"group","repeats":false,"readOnly":true,"id":"item.11.item.7.item.6","description":"The patient has an unstageable deep tissue injury."},{"linkId":"Section-13/M0300A1","prefix":"M0300A1","text":"Number of Stage 1 pressure injuries","type":"integer","repeats":false,"readOnly":false,"maxLength":1,"id":"item.11.item.8","description":"How many Stage 1 pressure injuries does the patient have?"},{"linkId":"Section-14","code":[{"system":"http://loinc.org","code":"88872-7","display":"IRF-PAI v2.0 - Medications - admission [CMS Assessment]"}],"text":"Section N: Medications","type":"group","readOnly":true,"item":[{"linkId":"Section-14/N2001","prefix":"N2001","text":"Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}],"id":"item.12.item.0"},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Medication Follow-up. Did the {facility/setting} contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.12.item.1"}],"id":"item.12","description":"In Section N of the form, the medications that the patient is currently taking are listed."},{"linkId":"Section-14/N2001","prefix":"N2001","text":"Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27634-7","display":"No - No issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27635-4","display":"Yes - Issues found during review"}},{"valueCoding":{"system":"http://del.cms.gov","code":"9","display":"Not applicable - {Patient/Resident} is not taking any medications"}},{"valueCoding":{"system":"http://loinc.org","code":"LA27636-2","display":"NA - Patient is not taking any medications"}}],"id":"item.12.item.0","description":"Did a complete drug regimen review identify any potential clinically significant medication issues for the patient? The options are 'Yes', 'No', and 'Not applicable'."},{"linkId":"Section-14/N2003","prefix":"N2003","text":"Medication Follow-up. Did the {facility/setting} contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?","type":"choice","repeats":false,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"0","display":"No"}},{"valueCoding":{"system":"http://loinc.org","code":"LA32-8","display":"No"}},{"valueCoding":{"system":"http://del.cms.gov","code":"1","display":"Yes"}},{"valueCoding":{"system":"http://loinc.org","code":"LA33-6","display":"Yes"}}],"id":"item.12.item.1","description":"Did the facility or setting in question contact a physician or a physician's designee by midnight of the following calendar day and complete the prescribed or recommended actions in response to the identified potential clinically significant medication issues related to the patient?"},{"linkId":"Section-15","code":[{"system":"http://loinc.org","code":"83261-8","display":"IRF-PAI v3.0 - Special treatments, procedures, and programs - admission [CMS Assessment]"}],"text":"Section O: Special Treatments, Procedures, and Programs","type":"group","readOnly":true,"item":[{"linkId":"Section-15/O0100","prefix":"O0100","text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that were performed","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}],"id":"item.13.item.0"}],"id":"item.13","description":"In Section O of the form, the patient is asked about special treatments, procedures, and programs they may have undergone."},{"linkId":"Section-15/O0100","prefix":"O0100","text":"Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that were performed","type":"choice","repeats":true,"readOnly":false,"answerOption":[{"valueCoding":{"system":"http://del.cms.gov","code":"N","display":"Total Parenteral Nutrition"}},{"valueCoding":{"system":"http://loinc.org","code":"LA10101-6","display":"Total parenteral nutrition"}}],"id":"item.13.item.0","description":"Please indicate all of the special treatments, procedures, and programs that were performed on the patient."},{"linkId":"Section-19","text":"Section Z: Assessment Administration","type":"group","readOnly":true,"item":[{"linkId":"Section-19/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0"},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1"},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2"},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3"},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4"},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5"},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6"},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7"},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8"},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9"},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10"},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11"}],"id":"item.14.item.0"}],"id":"item.14","description":"In Section Z of the form, the assessment administration for the patient is carried out."},{"linkId":"Section-19/Z0400","prefix":"Z0400","text":"Signature of Persons Completing the Assessment","type":"group","repeats":false,"readOnly":true,"item":[{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0"},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1"},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2"},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3"},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4"},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5"},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6"},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7"},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8"},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9"},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10"},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11"}],"id":"item.14.item.0","description":"The signature of the person who completed the assessment for the patient is required."},{"linkId":"Section-19/Z0400A","prefix":"Z0400A","text":"Signature, Title, Sections, Date Section Completed A","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.0","description":"The patient filled out the Signature, Title, Sections, and Date Section Completed A on the form."},{"linkId":"Section-19/Z0400B","prefix":"Z0400B","text":"Signature, Title, Sections, Date Section Completed B","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.1","description":"The patient needs to provide their signature, title, and date for the sections they have completed in Section B."},{"linkId":"Section-19/Z0400C","prefix":"Z0400C","text":"Signature, Title, Sections, Date Section Completed C","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.2","description":"The patient needs to complete the signature, title, and sections of the form, and indicate the date the section C was completed."},{"linkId":"Section-19/Z0400D","prefix":"Z0400D","text":"Signature, Title, Sections, Date Section Completed D","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.3","description":"The patient is required to provide their signature, title, and date the sections that have been completed in Section D."},{"linkId":"Section-19/Z0400E","prefix":"Z0400E","text":"Signature, Title, Sections, Date Section Completed E","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.4","description":"The patient needs to provide their signature, title, and the sections they have completed, along with the date they finished section E."},{"linkId":"Section-19/Z0400F","prefix":"Z0400F","text":"Signature, Title, Sections, Date Section Completed F","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.5","description":"The patient's form contains a section for the signature, title, and sections, and also records the date the section was completed."},{"linkId":"Section-19/Z0400G","prefix":"Z0400G","text":"Signature, Title, Sections, Date Section Completed G","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.6","description":"The patient is required to provide their signature, title, fill in the sections, and add the date the section was completed on form G."},{"linkId":"Section-19/Z0400H","prefix":"Z0400H","text":"Signature, Title, Sections, Date Section Completed H","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.7","description":"The patient's form contains sections for signature, title, and date, which need to be completed. In section H, the form is completed."},{"linkId":"Section-19/Z0400I","prefix":"Z0400I","text":"Signature, Title, Sections, Date Section Completed I","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.8","description":"The section titled \"Signature, Title, Sections, Date Section Completed I\" requires the patient's signature, their title, and the date on which they completed the section."},{"linkId":"Section-19/Z0400J","prefix":"Z0400J","text":"Signature, Title, Sections, Date Section Completed J","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.9","description":"The patient completed the signature, title, and sections on the form, and dated it on section J."},{"linkId":"Section-19/Z0400K","prefix":"Z0400K","text":"Signature, Title, Sections, Date Section Completed K","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.10","description":"The patient is required to provide their signature and title in the specified sections, and the date when they completed the form."},{"linkId":"Section-19/Z0400L","prefix":"Z0400L","text":"Signature, Title, Sections, Date Section Completed L","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.14.item.0.item.11","description":"The patient must provide their signature and title, complete all sections, and include the date that they completed the form."},{"linkId":"Section-49","text":"Therapy Information","type":"group","readOnly":true,"item":[{"linkId":"Section-49/O0401","prefix":"O0401","text":"Week 1: total number of minutes provided","type":"text","repeats":false,"readOnly":false,"item":[{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0"}],"id":"item.15.item.0"}],"id":"item.15","description":"The patient's therapy information is required."},{"linkId":"Section-49/O0401","prefix":"O0401","text":"Week 1: total number of minutes provided","type":"text","repeats":false,"readOnly":false,"item":[{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0"}],"id":"item.15.item.0","description":"In the first week, what was the total number of minutes of care provided to the patient?"},{"linkId":"Section-49/O0401A","prefix":"O0401A","text":"Physical therapy","type":"text","repeats":false,"readOnly":false,"maxLength":100,"id":"item.15.item.0.item.0","description":"Does the patient require physical therapy?"},null],"_id":"M9Mwg5CgffEfrWYCR"}